(navigation image)
Home American Libraries | Canadian Libraries | Universal Library | Community Texts | Project Gutenberg | Children's Library | Biodiversity Heritage Library | Additional Collections
Search: Advanced Search
Anonymous User (login or join us)
Upload
See other formats

Full text of "Lectures on the theory and practice of vaccination"

o 

T&IE WILLIAM PEPPER LIBRARY 

1 (T..vssGl4»4l3x,, C^LH 



LECTURES 

ON THE 

THEORY AND PRACTICE OF VACCINATION. 



LECTURES 

ON THE 

THEORY AND PRACTICE 

OF 

VACCINATION. 



BY 

ROBERT CORY, M.A., M.D. Cantab., F.R.C.P. Lond., 

PHYSICIAN IN CHARGE OF THE VACCINATION DEPARTMENT OF ST. THOMAS'S HOSPITAL 
TEACHER OF VACCINATION IN THE UNIVERSITY OF CAMBRIDGE, FTC. 



NEW YORK: 
WILLIAM WOOD & COMPANY. 



TO THE 
MEMORY OF MY DEAR FRIEND 

SIR GEORGE BUCHANAN, F.R.S., 

WHOSE EXAMPLE WAS 
AN ENSIGN TO ALL THAT WAS TRUE AND NOBLE, 
BUT AS A DRAG TO THAT WHICH WAS 
FALSE AND DISHONOURABLE. 



Digitized by the Internet Archive 
in 2013 



http://archive.org/details/lecturesontheoryOOcory 



PREFACE. 



For the last twenty-two years I have been engaged in the 
practice and teaching of vaccination. The six chapters 
contain the substance of the six lectures I periodically 
deliver to my pupils, together with the incorporation of 
several papers which I have from time to time published 
in the periodicals, and now for the first time publish 
in book form. The whole of the work was written before 
the final report of the Royal Commission on Vaccination 
was issued, except a short paragraph on page 8 and the 
completion of the report of the first case given on page 60. 
I am not, therefore, indebted to this for any information, 
and it may be taken, so far as I am concerned, as entirely 
independent. 

ROBERT CORY. 

73, Lambeth Palace Road, S.E., 
December, 1897 



CONTENTS 



LECTUEE I. 

PAGE 

THE REASONS WHICH LED THE LEGISLATURE OF THIS COUNTRY 
TO IMPOSE THE VACCINATION LAWS UPON THE PEOPLE, 
AND THE DUTY ENTAILED UPON EVERY MEDICAL MAN 
TO SUPPORT THOSE LAWS AT THE PRESENT TIME - 1 

LECTUEE IX 

HISTOLOGY OF THE VACCINE AND SMALL-POX VESICLES - 41 

LECTUEE III. 

THE DIFFERENCE BETWEEN A PRIMARY AND A SECONDARY 

VACCINATION - - - - - - 48 

LECTUEE IV. 

THE ERUPTIONS THAT OCCASIONALLY FOLLOW VACCINATION 63 

LECTUEE V. 

THE PRACTICAL DETAILS OF VACCINATION - - - 69 

LECTUEE VI. 

ON THE RELATION OF COW-POX, HORSE-POX, AND CAMEL- 
POX TO SMALL-POX ----- 1Q4 



LECTURES 

ON THE 

THEORY AND PRACTICE OF VACCINATION 



LECTUKE I. 

THE EEASONS WHICH LED THE LEGISLATURE OF THIS COUNTRY 
TO IMPOSE THE VACCINATION LAWS UPON THE PEOPLE, 
AND THE DUTY ENTAILED UPON EVERY MEDICAL MAN TO 
SUPPORT THOSE LAWS AT THE PRESENT TIME. 

A good introduction to the study of vaccination is a con- 
sideration of the reasons that led the legislature of this 
country to impose the vaccination laws upon the people, 
and the duty entailed on medical men to support those laws 
at the present time. This consideration is now all the 
more called for, as we no longer have the horrors of natural 
small-pox before us ; the unthinking are apt to overlook 
them and thus to magnify the nugatory evils of vaccina- 
tion, forgetting, or not considering, the saving of life and 
misery which we derive from it. 

Mr. Cross, writing in 1820 of the epidemic of small-pox 
which visited Norwich in 1819, says in conclusion : 

• I advocate vaccination because I believe it to be the 
most powerful means of preventing the misery attendant 
on disease, and of saving human life, which Providence has 
vouchsafed to put into the hands of man ; my time has been 
given up to the gratuitous practice of it, because I can thus 
do more good amongst the poor than by prescribing pills 
and potions, and I regard every drop of the vaccine ichor 
as the most active material that can be admitted into the 
list of our prophylactic remedies. I am, therefore, grateful 
to the philosopher who has taught us to wield this weapon 
of defence in overcoming the icorst of human maladies. 

1 



2 THEORY AND PRACTICE OF VACCINATION 



' The more we reflect upon the professional career of 
Jenner, the more must he excite our admiration for the 
scientific investigations by which he established his dis- 
covery — the nobleness with which he gave it fully to the 
public — the temper and ability with which he defended it 
against opponents often not of the best character. May his 
life be uniformly happy, and his name immortal !'* 

Such was the opinion of Mr. Cross, writing in 1820 ; and 
be it remembered that the discovery of vaccination had 
only been published twenty-two years, and its adoption had 
not become general, consequently he was writing with most 
of the horrors of small-pox still before him. He calls 
small-pox ' the worst of human maladies.' Worst, because 
it was the most common, and withal the most fatal disease 
to which the human race was liable ; scarring, or not 
unfrequently blinding, those it did not destroy. 

Of those who died in London from all causes, small-pox 
occasioned death in one-twelfth — that is to say, the average 
yearly deaths from small -pox would have been 6,577, if 
the same mortality was occasioned by it at the present 
time as was occasioned by it in the last century, instead of 
only 1,227, which is the actual average mortality from small- 
pox in London for a like period, and that period embraces 
the great epidemic of 1871. The average yearly deaths 
from small-pox that occurred between the period of 1867 
and 1885, and the annual average of deaths from all causes, 
have been taken for the above comparison, as it is wished 
to show, as far as possible, the effects of vaccination alone 
on small-pox. 1867 was the year of the Amended Vaccina- 
tion Act, and 1885 was the year when deportation of small- 
pox first took place from London, and deportation seems to 
have had a very great influence in diminishing the disease. 

The diminution of small-pox must be looked at from at 
least two sides ; that is to say, from the diminished in- 
fectibility of the population, which is what vaccination is 
capable of bringing about, and also from the diminished 

* ' A History of the Variolous Epidemic which occurred in Norwich 
in 1819,' by John Cross. 



THEORY AND PRACTICE OF VACCINATION 



infectiveness of the disease, which is what deportation is 
capable of doing. 

Mr. Power, the Assistant Medical Officer of the Local 
Government Board, has shown, in the report of the Board 
for 1880-81, that small-pox was especially prevalent round 
about the small-pox hospital at Fulham, and this prevalence 
could not be attributed to direct personal infection. Some- 
thing akin to this observation of Mr. Power's had been 
noticed by Mr. Cross during the Norwich epidemic of small- 
pox in 1819. For he writes, ' It is certain that the epidemic 
at its commencement was milder. The first petechial case 
which I saw was in the latter end of May. The virulence 
of the contagion seemed to keep pace with the increasing 
prevalence of the disease, and to be heightened in proportion 
to the number suffering from it at one time.'* 

To Mr. Power, however, we are indebted for having con- 
clusively shown that, from the segregation of cases of small- 
pox at the Fulham Small-pox Hospital, small-pox was 
rendered more prevalent in the region of the hospital. 

Further evidence on this point may be gathered from, 
first, the epidemic which took place at Sheffield in 1887-88. f 
Here there was a hospital for small- pox in a populous 
neighbourhood, and, as with the epidemic at Gloucester, 
where similar conditions existed, reported on by Dr. Sidney 
Coupland, the epidemic of small-pox was severe. On the 
other hand, at Leicester, where the small-pox hospital is 
situated outside registration Leicester, small-pox is apparently 
trifling. ' Outside registration Leicester ' is mentioned 
because it is not wished to attach undue weight to the 
argument. Pains are taken at Leicester to remove as early 
as possible cases of small-pox to the hospital, and if the 
patient dies, the case is not registered in Leicester, but in 
the district where the hospital is situated ; hence, Leicester 
appears freer from small-pox than is actually the case. 

* ' A History of the Variolous Epidemic which occurred in Norwich 
in 1819,' by John Cross, p. 14. 

t Report on an Epidemic of Small-pox at Sheffield, 1887-88, by Dr. 
Barry, of the Local Government Board. 

1—2 



4 



THEORY AND PRACTICE OF VACCINATION 



The outcome of Mr. Power's observations was, that cases 
of small-pox when notified have been sent out of London 
to ships or hospitals quite away from human habitation. 
The result has been quite phenomenal ; for small-pox deaths, 
which on the average for the ten previous years to the 
deportation of small-pox had been 1,121, fell in the succeed- 
ing nine years to a yearly average of only 43*4, or of 
what they had been. 

But diminished number of deaths from small -pox is only 
a part of the good derived from vaccination, for those whom 
small-pox slays at the present day have attained, on the 
average, to at least fifteen years' longer life than those who 
died from it in pre- vaccination times. 

Small-pox, before the introduction of vaccination, was 
really a disease of childhood, as whooping-cough, measles, 
and scarlet fever are at the present day, and consequently 
nearly the whole death-rate used to fall upon the children, 
just as the above-named diseases do at the present time, 
and individuals did not have small-pox later in life because 
they had obtained their protection by having had an attack 
in infancy. That this was the case may be gathered from 
records of the deaths from small-pox at Warrington, at 
Chester, at Kilmarnock, at Manchester, and from Geneva. 
The following table (Table I.) has been drawn up to show 
the age, as far as possible, at time of death from small-pox 
at these places in pre- vaccination times. It will be seen 
that 83-15 per cent, of the deaths from small-pox occurred 
in children under 5 years of age, and as many as 96*75 
occurred in children under 10 years. At the present time 
the greatest number of deaths from small-pox among those 
who have been vaccinated in infancy takes place between 
the ages of 20 to 40, and not in early childhood as in the pre- 
vaccination times. See a, Table II., p. 6. In Table III., p. 6, 
the ages in the pre-vaccination times and the present time 
are contrasted. 

This later table shows how greatly the age of death from 
small-pox has been altered. This, no doubt, is partly due 
to the present opportunities of being affected by small-pox 



THEORY AND PRACTICE OF VACCINATION 



rQ O 

^ £ to 

.2 2- 

^ ^ "o 

r -p s 

5« j? O 



£<1~ 

^ co~ 

Q- CS 

4- C ^ 
7} r. CI 

o oo 

t>> rHrH 



'H HI ^ 

O jo 

h o.2 

£ s - 

o a * 



23 ~ 

O 



^ 00 



5 s W 



15 c^ 
r* O 

S 2^ 



CO 



o £ . 

-P .2 

o 

~, rH S C3 



O P3 c3 

0^2 

° 5 O 



+2^0 r=3 



<D CD "73 CO 

2os 
+ 1 2 See 

_ rH 02 rH 



6 



» CD 
ill 

O 



Total. 


r-i <N "M OS 
O O OO 
CN CN CO IO 


1664 


6792 


8456 


Age not 
stated. 










Years 
20-40. 




CN 
>— 1 rH 

^6 


o 

NH OO 

_ CN 

rH 

OO 


CO 

Cl • 


Years 
10-20. 


«P r-rr 1 
o o 


CO 


180 

£i 0O 


185 
2-19 


Years 
5-10. 


12 
4-78 

22 
10-89 

21 

3- 38 

29 

4- 92 


o 
CO • 
ICS 


1058 

10 Oo 


1142 
13-60 


Years 
1-5. 


O CO -*±l HH 
Oj^. C5 OO OOCN CirH 

os • cn • co r-i - , 

H « T—iro tH O H 

CO W 


<° 22 

o 7^ 

^ CN 


cs 

"'H O 
IO 00 


^£ 

no • 

O CO 
W OO 


Year 
0-1. 


CN \0 1^ W 

C5»P r-|tN ^ 05 ^ V" 

**C5 ^ O rHCO h W 
r-l (N r-H CM 


358 
21-51 




Warrington, 1773 ... 
Per cent 

Chester, 1774* 

Per cent 

Kilmarnock, 1728-64 
Per cent 

Manchester, 1768-74 
Per cent 


Total 

Per cent. . . . 


Geneva., 1580-1760 ... 
Per cent 


Total 

Per cent. . . . 



2 " • 

o So 

r-i ^OO 



■a 2^ 



^ 13 H 



. ©.a 

O S 2 
O ^ r> 



"5.3 ° 
o 



6 THEORY AND PRACTICE OF VACCINATION 

Table II. 



A. VACCINATED BEFORE DEPORTATION. 



Years. 


Age 


Age 


Age 


Age 


Age 


Age 


80 and 


Deaths from all 


0-1. 


1-5. 


5-20. 


20-40. 


40-60. 


60-S0. 


upwards. 


causes. 


1882 


1 


3 


21 


57 


20 


5 


1 


82,905 


1 QQO 

looo 




1 


7 


27 


7 






80,578 


1884 


1 


7 


38 


142 


56 


6 




83,050 


1885 


4 


2 


35 


135 


32 


9 


1 


80 ; 000 


Total ... 


6 


13 


101 


361 


115 


20 


2 


326,483 


Per cent. 


0-97 


2-1 


16-34 


58-41 


18-61 


3-24 


0-32 




Total cases, 618 = 


= 0*19 per cent, to total deaths. 






B.- 


— UNVACCINATED BEFORE 


DEPORTATION. 


Years. 


Age 


Age 


Age 


Age 


Age 


Age 


80 and 


Deaths from all 




0-1. 


1-5. 


5-20. 


20-40. 


40-60. 


60-80. 


upwards. 


causes. 


1882 


22 


34 


68 


49 


11 








1883 


12 


12 


18 


10 


2 


1 






1884 


60 


84 


92 


60 


19 


3 


1 




1885 


66 


55 


110 


74 


19 


6 






Total ... 


160 


185 


288 


193 


51 


10 


1 




Per cent. 


18-02 ! 20-84 

1 


32-43 


21-73 


5-74 


1-13 


o-ii 





Total cases, 888 = 0-27 per cent, to total deaths. 

Table III. 





Age 
0-5. 


Age 
5-10. 


Age 
10-20. 


Age 
20-40. 


Age 
40-60. 


Age 
60-80. 


80 and 

up- 
wards. 


Pre -vaccination times - 
Present 


83-15 
3-07 


15- 79 

16- 34 


15- 79 

16- 34 


1-16 

58-41 




18*61 




3-24 




•32 



being so much less than they were formerly. But it must 
be mainly due to the evanescent protection which infantile 
vaccination gives. 

The protective power of vaccination is further shown in 
Table IV., which was drawn up by the late Dr. Carsten, of 
the Hague. It gives the average deaths from small-pox in 
Germany before compulsory vaccination at the age of 12 
was enforced, and also the annual deaths from small-pox 
since. The same is also given for Holland as far as possible, 
for Holland has no direct compulsory law. Every child in 



Table IV. 



PR USS1A. • HOLLAND. 

With CvmpuLsorvYarriiialioii Wiih Compulsory 

ti/ifi Compulsory Re^cuxurtoctioTt,. VaxxxnutLon of ChzLdrerv 
at th#< Ag& of 12. before, eiUjering a School . 



AUSTRIA 

Without Qimpulsoiy 
VcLcd natxDn, . 



Before the 
L cuv. 



After the Law of 1874- 

was passed,. 



II .ill... 



Before the; 
Law. 



After- Our Law of 1873 
was passed 



li|_iJ 



1.1 



-J2C 



_II0 



^00 



-90 



JSO 



.60 



50 



40 



80 



W 



-JO 



1868-1874 KSPSSSSxSwSSS 
lua ape yearly * 

Deaths from Annual Deaths from 

'^ICVOOO ^ ma ^ / ^ ooc > n/ every 
InhaiUcvas 100,000 Inhabitants. 



1866-1872 

Average \earlv 
Broth/ from, 
Small Poa in 
everv WO.CCC 
Inhabitant v 



c 

Annual Deaths from 
Small Poo- in every 
100,000 Inhabitants. 



1868 1874 

Average yearly 
Deaihsfronv 
Small -Pox in 
every WOflOO 
Inliabitante . 



IS3 



Antuial Deaths from 
Small -Pox in every 
100,000 Inhabitants. 



West Newma/n H.th. 



THEORY AND PRACTICE OF VACCINATION 7 



Holland has to be vaccinated before it enters a school, and 
the law compels every child to be sent to school. The same 
is given for Austria, where there is no compulsory vaccination 
of any kind, and here it will be seen how the annual deaths 
from small-pox remain high. The protective power of vac- 
cination is, moreover, shown by examination of the arms for 
vaccination scars among those who are pitted with small-pox. 

Since November, 1884, I have observed, whenever pos- 
sible, the scars of vaccination, if such existed, on every 
person who had become pitted with the small-pox which 
came before me at St. Thomas's Hospital and at the 
vaccination stations with which I am connected. These 
persons have been almost all women ; indeed, out of 456 
cases in which inspection was permitted, only 19 were among 
males. Every case examined is given in Table VI., p. 12. In 
18881 had collected 152 cases, which were published in the 
' Transactions of the Epidemiological Society ' for 1887-88. 

In what follows hereafter, Cases 24, 37, 65, 96, 131, 
246, 274, and 362 are eliminated from consideration for 
the following reasons : Cases 24, 37, and 362, because the 
vaccination took place during the incubatory period of 
small-pox ; Cases 65, 131, and 274, because, although they 
had some indistinct mottling, it was impossible to conclude 
with any certainty that this was the result of vaccination ; 
Case 96, because from the history it seemed certain that 
she had not had her attack of small-pox until eleven years 
old, although she stated that she had had two attacks, one 
at two years of age, the other at eleven years of age ; and 
lastly, Case 246 because I was not permitted to examine 
the arm. There are, therefore, 456 — 8 = 448 cases to be 
dealt with. Out of these 448 cases there are 210 who were 
admittedly unvaccinated before their attack of small-pox, or 
46*87 per cent. ; and these admittedly unvaccinated people 
had their small-pox at the average age of 6*58 years, as will 
be seen at the end of Table VII., p. 29. This age is indeed 
high when compared with the average age individuals were 
attacked with the disease in the last century. However, 
there are three circumstances to be borne in mind : Firstly, 



8 



THEORY AND PRACTICE OF VACCINATION 



the greatly diminished prevalence of small-pox in the present 
day to that which obtained in the last century. It follows, 
therefore, that the opportunity to become affected is 
correspondingly not so great, and this would delay the 
average age at which unvaccinated individuals contract the 
disease. Secondly, a large proportion of the unvaccinated 
individuals die of the disease, and these would in the main 
be the infants ; hence we have a considerable portion of the 
youngest eliminated by death. And, thirdly, only those 
who have been obviously pitted with small-pox are dealt 
with. There are some individuals who, although they have 
had the disease, yet are not obviously pitted. If these 
could be added, no doubt the average age would be 
diminished at which small-pox attacks the unvaccinated. 
There are, besides the admittedly unvaccinated, as many 
as 105 individuals who, although they say they have been 
vaccinated, yet have no scar of vaccination, or 23*44. As 
a matter of fact, there are as many as 70*31 per cent, 
among those who are pitted with the small-pox who bear 
no evidence of vaccination. An opinion can be formed 
of how many of the latter class may be reckoned among 
the unvaccinated thus : At Lamb's Conduit Street Vaccina- 
tion Station, since it was opened in 1882 until March in 
the present year, 1,774 women have been revaccinated. 
Of these 82 had no scar of their primary vaccination, and 
22 out of the 82 went through their presumed revaccina- 
tion exactly like a primary vaccination, or 26*83 per cent. 
On the other hand, out of 1,692 women who bore scars 
of vaccination, it was found that 47 of them went through 
their revaccination like a primary vaccination in all respects, 
or 2*78 per cent. If now this latter percentage be deducted 
from the 26*83 per cent., we obtain 24*05 per cent, as the 
number who really had never been vaccinated. 

From these data we can calculate that of the 105 cases 
which have no scar of vaccination, 25*25 should be added to 
the 210 admittedly unvaccinated ; this will give then 235*25 
as really the number of unvaccinated among the 448 cases, 
or 52*51 per cent. 



THEORY AND PRACTICE OF VACCINATION 9 



Now, the proportion of the unvaccinated to the vaccinated 
in London is not more than 5 per cent., yet we have seen 
that people pitted with small-pox are to the extent of 52*51 
per cent, unvaccinated ; and if, as some contend, there is 
no protective power in vaccination against the small-pox, 
what is the meaning of this ? I leave this question to be 
answered by those who hold the above view. For myself, 
I am content to believe there is protection afforded by 
vaccination against small-pox, and adduce this as one out 
of many proofs that such is the case. 

At the end of Table VII., p. 33, it will be seen that the 
average age of 105 individuals who affirm they have been 
vaccinated, but have nevertheless no scar of vaccination, is 
9*07 years when they are attacked by small-pox, and it has 
just been seen there is good reason for believing that 25*25 
of them have never really been successfully vaccinated ; 
and as the average age at which the admittedly unvac- 
cinated have their small-pox is 6*58, therefore 6*58x25*25 
= 166*14, which is the aggregate age at which we may 
reasonably suppose they had their small - pox. This 
deducted from 952*64 years, the aggregate age at which 
people affirm they have been vaccinated but have no 
scar, equals 786*5, and this divided by 105-25*25 = 79*75, 

j^y| = 9*86. Hence this is the average at which those 

who may be supposed to have been really vaccinated, but 
who bear no scar of vaccination, have their small-pox. 

From Table VII. it will also be seen that those who bear 
one scar of vaccination have their small-pox at the average 
age of 17*77, the earliest age being 2. That those who 
have two scars of vaccination have their small-pox at the 
average age of 17*82, the earliest age being 7. That those 
having three vaccination scars have their small-pox at the 
average age of 18*02, the earliest age being 9. That those 
having four vaccination scars have their small-pox at the 
average age of 18*67, the earliest age being 12 ; and those 
having five or more scars have their small-pox at the 
average age of 19 3, the easiest age being 13. 



io THEORY AND PRACTICE OF VACCINATION 

It will be noticed not only does the average age at the 
time of having small-pox increase directly as the number 
of the scars, but also the earliest age at which people 
become liable to contract small-pox after vaccination also 
increases in the same way, so that we may conclude that 
vaccination done in five places gives a longer time of 
immunity from small-pox than when it is only done in 
one. It has been stated that Cases 24, 37, 362, were 
eliminated from consideration, because vaccination was 
performed during the incubatory period of small -pox. 
Perhaps the reason why may not be obvious to all, and 
it will not be thought superfluous if it is more fully stated. 

The history of Cases 24 and 37 cannot now be given, 
but that of 362 will serve as an illustration. The girl, 
who was twenty-three years of age, had her face scarred 
in the manner faces are scarred when a person has never 
been vaccinated ; and, moreover, the severity of the attack 
was further evinced by her having lost an eye through 
the disease, which she had, as she stated, when she was 
only fourteen months old, after vaccination. Upon question- 
ing her as to her vaccination, she alleged she was vac- 
cinated before she had small-pox, and on examining her 
arms six large foveated and well-marked scars of vaccina- 
tion existed, three on each arm, and arranged in the same 
pattern as my predecessor Mr. Marson was in the habit 
of placing his insertions of lymph. From the appearance 
of the scars I could not doubt but they were done before 
her attack of small-pox. So much, then, was all that could 
be gathered from the patient herself ; but I ascertained her 
mother's address, and upon calling, her mother told me 
that her husband was seized with the small - pox one 
Wednesday, and she took her children, who had not been 
vaccinated, to Surrey Chapel on the following Tuesday, 
and that the child in question was taken ill with small-pox 
on the following Saturday. This girl was therefore vacci- 
nated on the seventh day of the incubatory period of small- 
pox. In connection with this, the ■ following- cases maybe 
mentioned : Three children \>\ire vaccmateci at Surrey 



TahleY. 



Diagram showing, the Mortality in London irom Small Pox, Measles Whooping Cough. 

from 1760 to 18.90. 
1760-70 70-80 H0-9090-18V(i Oto10 10-20 20-30 30 40 40-50 50-60 60 70 7C-80 80~90. 



7.5 
70 
165 



■5 240 
I 235 
I 230 

k 225 

t % 215 

•3 o 200 

- ^ c 19b 
&«| £ 190 

' | eg 185 

• 3^ 

~ 160 
155 

Chester 150 
luge, for 745 
6.jears 140 
9-1774. 735 

7,30 
126 
120 
115 
110 
105 
100 
•OTicLon 

85 
80 

75 
70 
65 
60 

55 
50 
45 
40 
35 
30 
25 
20 

London ~ 
Meccsles 
Whoopmg<, O 
Coughs | 
Zorulxm.. 
































































































1 





















































































































































































































































-| 




































































































1 




























































1 • 














































































































I 





















































=R 


























— I — 






































; 1 
























































































\ 


























v~ 










' 










































































— N; 






































— I — 










































































/ 




























/ 

/ 




























/ . 






















/ 




























✓ / 










I,. 


















/ / 


























s 


/ 






I 




















y 
















































































Small-Pox 
Average 
Death from 
S.PXUmam k 
1728-1764 



Snudl-Pox 

Whooping 
Cough 
Measles 



West, Wevrnian lith. 



THEORY AND PRACTICE OF VACCINATION n 

Chapel, or, I should say, at Victoria Hall, on May 26, 
1881. This turned out to be on the ninth day of the 
incubatory period of small-pox in two, and the seventh day 
of the incubatory period in one. All the children had 
small-pox in its unmodified form, yet all the vaccination 
places had taken perfectly, and were well formed. 

The youngest, aged eight, died of small-pox. The other 
two were seen again, one on June 15, 1895, and she then 
bore five scars of vaccination ; and one on July 10, 1895. 
He also bore five scars of vaccination. They were both 
much pitted with the small-pox. 

The history of Case 96, which is also one of the excluded 

ones, is the following : Mrs. L. S. A , set. 22, states that 

she has had small-pox twice, the first attack at the age 
of two, the second at the age of eleven years. She said 
she had been successfully vaccinated in infancy, and, 
indeed, bore three well-marked and characteristic scars of 
vaccination. She also said that seven others, her brothers 
and sisters, all had the disease at the same time, although 
they had all been vaccinated ; that they all recovered, and 
that not one of them is pitted, and that she herself was 
not pitted from this attack of small-pox. She states her 
second attack was at the age of eleven years ; that she was 
sent to the hospital ship Atlas, and afterwards to Deptford ; 
that from this attack she was pitted, and had since suffered 
from disease of the hip-joint in consequence of the attack. 
If this history were true, we should have to believe that 
she had an attack of small-pox within two years of a 
successful vaccination done in three places. That this 
attack of small-pox did not take place during an epidemic 
year, but in one in which London was remarkably free from 
the disease, viz., in 1875. That not only she, but seven of 
her brothers and sisters, all of whom had been vaccinated 
likewise, had the complaint; nevertheless all recovered, and 
not one of them was pitted. That she again suffered from 
the disease within nine years of her alleged first attack. 
The whole history is so full of glaring improbabilities that 
we cannot but feel justified in excluding it from Table VII. 



THEORY AND PRACTICE OF VACCINATION 



o co m 



CO CO 



CO CO HH CO CN 



^ cr; <1 £ £Q <1 



R 
c3 

?H > Tj 



„n3 i^+-> co o S 

° "S 03 r=3 Z CO 

03 S co > O TJ 

-H « O r3 O 



c3 08 i"2 



• S 03 CO "> 



'S, 



O CO 



as a co 



c3 P-i'i? "3 £ 



0»ONOOC5(0 

© m © m © © 
oo co co oo oo oo oo 



co i— i co co 
co co oo w 

oo oo oo oo oo 



NGCO 
O CO m 

oo oo oo 



CO (N OS «D >0 

co co m co co 
oo oo oo oo oo 



a. o co o oo o o t^t^t^ 

CO C5 OJ 03 OO OO OS OO OO 00 

oo oo oo oo co oo oo oo oo oo 



00 © 

00 CO 
00 oo 



HOW 

o co co 

CO 00 00 



© © i-t o © 

© o © co © 
oo oo oo oo oo 



<4H O 

q <o 



co"w"o~^ 

CM rH rH rH 



CN 



-8 5.3-6 
ph<5h;o 



co . co 4J r t>^ CO . • 

***** til 



3 CO ^ b 



■HH © © TP © © © 

CM CM CM H 

°cT'2 3 j!"S t 3J3 r 5 

H^ ^ O ^ <=< l-j 



° c S ^9 



50 C3.3 

^ s - ^ >> 

-h *- 5 w 

■2 



"I S co £po 

H 03 s-. S Cl, 
p 



HH O 



Age 
when 

at- 
tacked. 


03 

t>>CO CON^HHCO 
03 f-i CM CM CM 

Q 


O CM CM 
CO TP 


CM CM 


CM © rH 

^ tp CO 


© 


CO © © rH rH 

© © © © © 




«D tD I>i H m t)h M 


CO "M © 


m © 


oo © © 


© 


© m © t^- oo 


. to O 


© © © co co in oo 


OO CO "* 


© o 


m m i-h 


CO 


OS CO H^ <M (M 


go.o 


CM CO CO i-h (M (M 




I-H CM 


CO CM 


CM 


CM CO CO CN CO 


No. in 
scries. 


H (N CO ^ O ® N 


00 © © 


r-H O-l 


co in 


© 
I— 1 


t^. 00 © © rH 
rH rH rl CN CN 



THEORY AND PRACTICE OF VACCINATION 



13 



N m c: m 




ti s s 

T3 9 2 P t- 

£ £ P O £ ^ 

2 o r; r o o3 

= J § §^ S § g g 



eo 10 --3 

00 00 GO 



00 oc 00 00 00 oc 00 00 00 



OOONH 

CO CO OO GO 



(M©ooC!?q^a^ 
mio-^^titocococo 
00 00 00 00 00 &o 00 00 



©co-^tMoocomo 

OO OO OO OO CO QO OO OO CO 



CI 1^ 

co co co 



0000305 00 00COCOCJ 

cooocococococococo 



^iflNlO ^ N (35 N CO IT. N Oi 

01 co co o co 00 00 co co Ci co 00 
co co 00 co cocococococccoco 



NNl^NN CO CO CO © 

co co co 00 co co co 00 co 
cooocococococococo 



+5 ,£> ,0^!=^°^^^=:^ 



<< <1 <j £ g £ £ s 



> > Cjj > > > > > 



> > > 



£ Jzj fc" 



?> c. > ^ ; f> > > ! 



CO CO CO 
CO 1— 1 1— I -rH 
t-h 1-1 CM CM CM 



1^ 1^ O © O CO CO 
CMCMcMCOCOCOCOCO 



CTi (M 

1 — CO CM 
CM rH 



H H t|( O CN © CO M t)( CO (NNN CMl>.CM00-^O5CMCO 
OlOOOOOlfN^COO 1— I J>- OH^^lOiQNO 
CM^^CM HHNM H CN i-l-"* CM 



N«O^OCOCSHNO 
•*0)OON^C0C0f: 
HHrtHHHIN 



'4 



THEORY AND PRACTICE OF VACCINATION 



8 53 8 ^ rc> 

CNjTjiCOCOCNCOCO^fiCO 



:o co ^ oi •N co 



e3 e8 

s s 

W GQ 

CD 

> > 

O O 



-3 cotS 

CD t„ © 
+? O ' 



« as ft 



a rz 



""3 ^ 

■+J CD CP ^ 45 rft' 

© A g 

O +i w CD 



O rH 

J? r-, 
^^^^ 

r3 H -s) - 



cd oT^a 



&0 



^ Sb CD 



x x <=; — — xSS^O 



x x x 



Year 
patient 
had 
small- 
pox 


rHCliHONW-T<0^rH1^0r-iCONNOCOTtlQ r r>C/}CO>fJ-HT^t^05 00r-l 

L~ CO w CO UO 'Z ^z C. CO -Z ID L~ i~. — — -_r — ■ Ol -z — T-l o vc: — — 1 

cococ»c©ooc©c©cocx)cx}coccoocococx)oocc 


Date of 
Observation. 


CffiQOOOHCO^NNNNN-fC.NinNNNNNOOCO l»a C. O". T- C3J 

cccocooiaoffiocccxoococofficoMcoooxxxoccoxxxyKMco 

COCOCOC/DC»COCX>CX)C»COaOCX>CX)COC»C»COro 

COrflNHrtOiOOacOOiOlNTtHONH ©i I^T CO i— irtHCfiTjuSMMWO 
<M I— 1 r-H (M (M M M T-H i—H CN l-i Oxl CN1 04 t-I <-H 

45 +5 £ ,q >> > jyS c5 *s 2 2 &b cd -~ ^ % w:^ £ > «£ 2 bb^ tfc+s j +j 


Age of 
patient 
at time 

of 
obser- 
vation. 




If vaccinated, 
number and area of scars, 
the average diameter 
of scar represented 
by a line. 


o : o o o : : : : : <=->• : : o o : o : : ; : : : : © : : : o o " 


Whether 
vaccinated 
with effect 
before 
having 
sm nil -pox. 


C ^ O « H ^ > H ^ '3' ^ H « « >- > >- ^ H H H H c H ^ H O « ^ 


Age 
when 

at- 
tacked. 


!OM CO 

, — :^ ir; c c c c co 




iC N ir. O (M N H r- »M O ■# 1C H CO CI H !fi O O N « O ^ CO OO o c: N "3 a 
C W N c: C O C M 3 O CT. M N N i— tCOOi— 'r- iOI-ctOWCS-^OSOO 
(M!MCM^lCOCOCO-^^r-H i— i :N rinnrtHHrtrllNtNINlN 


No. in 

so ies. 


»q rN«ooHCMmT«in«oNcoc50r^^::-<ir: osoooOHCNM^in 

W C C. ». C w (O a w O S CD Cfi (O tfl N N M» N N N N N N OO M M CO CO CO 



THEORY AND PRACTICE OF VACCINATION 



>5 



CO CO CM CO CO CC O ^ M CO CO CO CO 



ri 



co 3 
3 "o 



to > o 



03 <D r ^ l '§ 

2 2 fc^-S 



o 

« as 



03 >> 



O cS -rt cj Ch cj P-i-i-h ■—! C CJ 
E-j i_q CX, eg QQ a! cc X 2-i O M GO 



£ PI'® H 

O 5^ 3 rt » j> 



; 5 Ca- 
re* 4-3 



Cj 
CO 

5 

05 

5 "o 

cS CD 

8 3 



4-J t-i 



^ CO 



2-, 



W CO 



o c 
CO 



O O O « C. N H 

o >r. w O ^ N 

oo co oo oo x oo co 



CO Ci CO a O N C5 N N O CO 00 S> N C C fl « ^ J5 O CO tJ( N 

N O !D CO « CO o a o » to «o r 1 CO n to ffl C i.-: O ?C w N to «o 
cococowxxcococoodcococococococowcocococooo^x 



O O O O CM CO CO Kl CO t< iO N CO CO OS ^ CO N N N N N N N N OO OO CJ C! O) ^ CD O O O 

CJ CS CJ C5 CS CI Ol OJ CJ C. CJ CO CO CO CO C. COCOoOXCOCOXCOOOOOOOCOCOCOXCO'.iCJ CJ 
CO CO CO X X CO CO XXXXXXXXXXXXXXXXXXXXXXXXXXX CO 



cS O " "CrC 3 O 



^ g £ S p! ^ ^ 60 fcO Pg *S bp 60 bo g 



l>» O (N OJ O X ^ 1>- CO CM CM • ■ 
CM rji CM CM ITS ^ CM i— I CO CO CM O CM 



CI O iCl X -t CO C^ C>1 CO IQ CO O X CJi r-i ^1 CJ CJ CO ^ 
" CM CM CM CM CM CM CM \Ci CM CM *tf CO CO CO CN CM r-i CM CM CM 



•— ■ 


> > «5 > "g > 


> > > ^ > > ^ _ > > > >■ >' >' >>>> > > > Cjj > > «jj 






~ £ ~ 


£ ft jzj ~ ft ft ft ft ft ft ft ft ft ^' ^" ^ ^ {zj ^ ^ ^ ^ ^ ^ ^ 








CO 

lO C C IQ C cO 




CM 


CM CM CM CM CM CM 


(MCMCMCMCMCMCMCMtMr^iCOCOCOCOCOM 


CO 


CO 


CO N CO CJ CO 
n H (N N CO OJ 
CO CO CO CO CO CO 


OMincOMtOWtO^rJOCJHOOiOMOlHtOLOXOOCN^O) 
a N N O CO X CJ CS ■* C. ^ O N X C. C O O C N r- M tii i - i- ct> 
eo^ti'*'^ rlHNf n r-l r-H r— CM CM CM CM CO CO 


CO 
CO 
CO 


co 

CO 


NXOOHIN 
CO CO 00 CJ CJ CJ 


CO^OCONXCDOrH^CCHLl-ONXaOriCNCOTflintONXCJ 


o 

CM 



16 



THEORY AND PRACTICE OF VACCINATION 



M C IT. ^ 



8 « § 

O* 0)'<».O 



co a> g o <x> 



g o_ p n g 



C 3 M >2 



S 

o 

ID 

O CD 

3 a 



M r—t 



r! ?! S hr.^ o t? ~ m >~ t; 



~ 2 5 



r5 ^ 



2 



.;r s .rr 2 s S 2 =3 " s 3 ■+-» 

■ rH !_L ^ ^_ ^ o O ^ 



1^ t>- C5 

in --o to 

co co go 



O CO .-i i-i W '<-i o 

cococococooococo 



(OCi-NHNCNOOCOvItJIHOOMMM 

cocococococococococococococococococo 



CT. OS Ci 

co 1 co co 



(N (N « W 'l* C N O 
CI CSCiClOCiOOCO 

cocococococccoco 



OKNNNXMCOXXXOCiOOHNN 

cocococooococococccocccococicicjcsco 
cococococooococococccococococococooo 



co't^cT cTir-f <^~co~cTi--^of w 

,-i i-l rH (M (N CN <N r-l 



<o*o ccT io" co~ irT ?cT*>r co" co' 

(N r-H i— I i— i i— I CN i— i 



C3 



CN i-h 

5 ?i a 3 ir 



5\ 

to o o 
■Pce.2»o 

ci fl >> 

a* o 



o3 

5 ! 



?:>>>>>> 

i ^ ^ ^ ^ ^ ^' 



>>>>>> ^ > > ^ ^ > > ^ > > 



cococo cococococococo 




C1Ct)< CC !N C O lO CD » 
CO l-^ N X C! O ^ O 
COCOCO CO CO CO T 



N CO N C N rH ^ N Cl O " ^ ~ O a t)( M rn 
HHrHrHr-IHHrH!NM^(NCOCO 



THEORY AND PRACTICE OF VACCINATION 17 



co >.-: -n co 



M <M <N CO CO 



f ! I * 

Ittf if ill-lit I Jii-liJI § jfl ££££££ 55 ix^s^ 

00 

lllllllllllilllsllll i|||s|||| 1 linn 



ii .1 

3 i_ 



o • o o 



q3 



r t 



- X ~ - ft ft ft ~ g g ~ ft ft ft ft ft ft }2i ft ~ ~ ~ ~ ft ft ^ ~ 



UO ip 

10 « >o c o 10 10 10 w o 10 o o 10 o w o iq o oiaiaiaffl^'-ooo to to co co co co co 



■1 



l8 



THEORY AND PRACTICE OF VACCINATION 



o H a 2 prt £ o ■— Us 

r£ ^ CD » ^ JJ UJ'O © 

-g o » 'I £ T: £ 

CM^coo^QroSoco 



(MNIMGOJNCONiSO-* 
N !D O lO C SO (O M O N 
COOOOOOOOOOOOOOOOOOOCO 



o 
O 

C t» 

CD r-l 

c3 g 
CD o 

^ £ 
1-1 ^ .(j 

cd ■— T-j 
SSI! 

co go co <s 



^~ a -- ir i 

E 2 as 

~ CD <K rrt 



.t: o a & ® .t; 



w o h co h a oj a o !>i 

tJ( 1Q K 1^ K t)1 <fl (O N N CO 

OOOOXOOCOOOODOOOOOOOO 



c3 eS 
o a 

CO CO 



4J 4J D 



CD CD 4^ .^frt +^ 

oa a: ^ ^z 1 y ~ 
c§ § &D O To 

(Li c.^ °> -1h 3 

GO GO GO Q P- CO 



CO CO ^ O 1^ 
® O (O N IC 

co cc co co co co 



c 

o 

OS 



mWOJ^Kl^NCOCOOO^ 
OOiCOCT. COCOCOCOCOCOCO 

co co co co co co oo co co co co 



OlOiOOOHHHNMCO 

oocociCiCiCiCiCiCiCici 
cocococooococococococo 



^ C5 <D N N 

a c» aj co co co 

CO CO 00 CO CO CO 



a 'a a ^ 3 d ^ 5.°^ 



lS'c Rh 3 5 a a *2 « 



d o g r= 



«3 



o 5 2 *■« 



-3 SI § 6 

£ 3 K >> 

> Ci 03 g,o 

a s £ s 








e3 




: : : o 


: : ; : : 


irfegul 



: © o : : : 






large 





: : © : 


fain 


stin 









55 £ ~ ~ £ 



CD J? , O 



0«0'-C'ONI»NNNN W 1^- t>. W W 1 ^ W 1^ I — W N OO CO CO CO 



t-i CO O O Oi O W CO w 



COT«OW^OlONMTt(H 
CM CO O CM CO O iCt ■ id X>~ CO C75 
CMCMCOCOCOCOCOCOCOCOCO 



<CO C3i CO CO CM CO 
CO Ci CM IC CO 
Tt< rH 



N CO a O H M -f IT, to N 
Ci Ci Ci O O O O O O O O 
T-Hr-<i-ICMCMCNCMCMCMCMCM 



00 Ci © i— I CM CO 

© O 1-H rH l-l r-4 

CM CM CM CM CM CM CM 



THEORY AND PRACTICE OF VACCINATION 



CO kO CO 



co i-i co \a o co 



t3 

© 

© 
a 



1 







i^H © 

GO OQ 



3^ 



S3 S^s^^^^S 3 
^ <g © 53 +3 43 03 a^s 

•3 w B 3 ,ss jd *fi ^ 
S if 3 iC iC be i£s o bO 

c © s — r; o c$ ^ 

O CC SO SQ 5C CO O ft( 03 



o © 
O 02 



c3 5* 



cc © 
O t-i 



o C ^ 

M go 



© t3 



— , c © © 

^ >>§ 



. ^ ^2 w © £ 

© 



iT3 S 



- -*3 .2- ^ 



s 

H P 



§ 5^ 



© © g> 53 q3 

§ BBSS 

go go Q-i m 



Tit „r 



3 3 IS 
© s ^ 



■+J +2 ^ 



co 00 CNScoHTjiiHao^oottunin t-h ©oocococooiocioo© in w cm 01 

1^ tO eD «0 "O "O i^NON!ONOONN^» CO © N (C N lO 3 1^ CO t». !>. CO CO 1^ CO 

OO CO CCOOOOCOCOCOCOOOCCCOCOCOCOCOCO CO COCCCOCOGOCOGOCOCOGO CO CC 00 CC CO 



CO X) j: r. f. o O N M M CO iO o 

CO CO 'CO CO CO OO CO OS CX CT. OS OS OS OS CI OS CO 

CO CO cococococococococococococococo 



NNNaaooio^Tf 
cococococoocsaaaics 
cococococooococococo 



W W CO 

CO CO CO CO 
CO CO CO CC 



nnOJO 



o ^ 



_ fcC > J "g 

© © c o S 



. © © © 
© 5 o 3 



C*_- 6^ > > > ^ ^ ----•>>> C,J ^ 54-" >> >► > >■ >■ etH C4J > t« >- CtJ 5jJ > 



COCOCOCOCCOOCOCOCOCOCOCOCOCOC75 



01010V01C31C50VOiCS05 



O CO ^i-HiCl--I^'-Ot^t^OC:OCMO«Oi-H OS CO O 1^ H O lO C~. (M O Tt< MM03 

o h r n a ^ a n h -m ^ c o h cn h co qo oo a o n co ^ n 

HH CNOI'NOICNCNCOCOCO'*'^-^^^ HHHCMCNCN^^^ r-1 r-H 



U3(0 NQOcr. 0--CMCOt<0«CH^COOOH CO^iOCNCCOiOH'N CO -#0(ON 

H fH i- l -rtMCN-^<NCQCM!NCN!N'NCOW CO COCOCOCOCOCOCO^^T ^ Tft^'T'r 
CM CM CN CN O! Ol C^ Ol C^ CM CM CM C^ CN1 CN1 CNI CN CM CMCMCNCNCMCMCMCMCMCN CM CM Ol "M "M 



2—2 



20 



THEORY AND PRACTICE OF VACCINATION 



I (M C>) K5 CO CO W O CO 



tJH -*jh CO CO CM 



Cj CO 



>>S 



ce 33 > S ^ g=: 



jj c6 O h £» 

o -J5 S g > .2 8 • ~ <u 

>>^2 o h 
O 



^ sr, 2 & 



' 5 'Ei 2 
,T3 



i O e8 pj 

' _H _ V O 



is a 



H 5- 00 ^ 



5/0 



Si3 to 

' C3 00 ,_, ^ r- 



3% 



S g o J 2 "| ^ 
» cj s p a § .h 

02 ^ PL, ^ 



CO oa 



§^5 



bO 

> w 



ft a 



lOHOOOONOOim i— I 
«CON(OOMON(0 CO 
OOOOOOOOCOOOOOCOCO OO 



H lO ^ rt 

CO CO t~ CO 

CO GO OO 00 



h « o co co o 

00 00 O 1^ CO 
OO OO CO CO 00 00 



OONCOOOO 
CO 00 CO CO 00 CO 



1! 

P 8 



ooooooooMooaooi 
cooococooooooocooo 



^ 3 5 03 o 3^6^ 
<! <i <5 co O ^5 



m N N CO 

CO 00 00 OO 
OO CO CO CO 



00 CO C3 OS CS 05 

oo co oo oo co co 



- ^ - O o S3 



O 1^ W I ^ W 1^ 

co co co co co co 
co co co oo co co 



,-Sj pt| fin <?} h-, ! 



MS*- 

•"5 ftc« 



CO 

-53 



eS co ^ co _g 

■S3 ci co Ph" -1 

k 2 o 

_ 00 K X 



© CO 
O > S 



JO ,d ao bo O 

A recc g a a 

,C y.fl g c3 ci 

> £ CO 



> -^j >■ > >► > c^- > 



> -~ ^ *J 



> ^ ^ ^ ^ 
£ {zj hh £ hh ~ ~ ~ ~ 



Age 
when 

at- 
tacked. 


ooooooooo 


b 






"M M CM CM CM CM 


No. in 
Case- 
book. 


WHCOWNCOINHlO 
HIN1<OmcOOO(NW 
CMCMCMCMCNCNrMCO'tf 


CM 
CM 
"<* 


lOCOO-* 

CO 00 


i—i £35 irj ON«0 

CO I-H CM I-H 

H CN CO CO 


i^. i— I t>. C75 VO 
CO Tji lO J>- 


No. in 
series. 


OOOSOi-HCNCO^OCD 
CM CM M M CM CM CM CM CM 


l£i 
CM 


OOOiOH 
ifliOCO© 
CM CM M M 


CM CO XO CO W 
CO CO CO CO CO CO 

CM (M CM CM CM CM 


00 OS O t— i CM CO 
CO ©NNNN 

CM CM CM CM CM CM 



THEORY AND PRACTICE OF VACCINATION 



co co cm 



CO CO CO 'N 



2 



63 ^3 H 



H 03 



O r-i 



£-i CP 

o o 



•73 'g «<— 



CP ^3 4j >lO 

O d P S H J 2' 

e§ O | § 



II 



4j CO 



i — o 

a: co 



.15 O 



+3 ,_, ^ j>> 
^ J) 

© £ C " — 
% a a 
es o a ^ 
Ph co co 



co co 



CM r-i CO 


Oi CM 


OOHON 


■HH r-, 


CM Oi O !>• t>- 


O T-H 


(N C. N ^ 


o 


CM t— 






CO 


K 00 00 


OO 


N N CO O W 


oo 


1^ W CO ir- 


CO 


GO W 




CO oo oo 


00 CO 


00 CO CO CO 


CO 00 


00 00 CO CO 00 


CO CO 


OO CO CO CO 


00 


CO CO 


00 


CO CT. 05 a 


Oi Oi 


Oi CM CM CM 


CO CO 


WWIONN 


!>. w 


00 Oi Oi O 


o 


o o 




OO GO OO GO 


CO' CO 


CO Oi Oi Oi 


Oi Oi 


Oi Oi CO CO CO 


co co 


OO 00 GO Oi 


Oi 


Ci Oi 


Oi 


GO GO GO CO 


CO CO 


CO CO CO 00 


00 OO 


CO CO CO GO GO 


00 oo 


CO GO CO CO 


CO 


OO CO 


CO 




t^- CO 




CM t-< 


Oi o »n oo 


CM W 




CC 


CO 




WrHH 


CM rH 


CM CN CM 


CM 


CM CO CM CM 




CO i — I r— i 









&J3 be be > 



«3 



^ HH S 



<3S Q 




*s «s 'S ^ ^ ^ 



CMCMCMCM CM CM CMCMCMCM CM CM CMCMCOCO 



COCO M CO CO CO CO CO 00 



O CO O IN CO 
IT, C. rH o-i cm ^ 
i-i i-i M CM CM CM 



OI O CM CO 
W CO 
CM CO CO CO 



\a t-- cm i— i tjh 

i-i i-i CM OZ I— 



Oi i— I 00 OO rH O t— i— I 
COCOCO00 O i— i i— i CO 
rH CM CM CM CO COCO CO 



^ >T. CO N OO Oi 
1- 1- W W W W 

CM CM CM CM CM (M 



O r-i CM CO 

CO GO CO CO 
CM CM CM CM 



OO OO 
CM CM 



CO W CO Oi O i — ! CM 
CO CO GO CO Oi Oi Oi 
CM CM CM CM CM CM CM 



CO ^* lO CD 
Oi Oi Oi Oi 
CM CM CM CM 





CO Oi 


- 


Oi 


Oi Oi 


C 


CM 


CM CM 


CO 



22 



THEORY AND PRACTICE OF VACCINATION 



CT C f (M K CI 



© ft) 



- — _ r - — -J 



,60 

53 



to 
53 



53 



M 3 .to 
55 x 53 



Pi CO ,3 



x x O 



X ~ X X 



: 5£ 



i-h 00 o (N 00 c o 

00 GO cc 00 00 GC 00 



CO tji COM 
N CO CC 1^ CC 

oc 00 oc 00 00 



ccOT-Hi^o^r-"'— 1 Ci'cN w cs 

NXXCXNXNNCj, WOO 

GOOCCCCCXCCCCOCGCGC 0C QO 



Ci 00 00 00 00 

00 CC X CO CO 



NO Ci Ci Ci 

oc 00 GO GO 00 
00 00 00 00 00 



OO^-CNt-t — utwi^ r_ x OS 

CI OS OS Ci C. C. C. X X X X X X 

CO 00 00 GO 00 CC GC X CO CC X X X 



cT to O r-T (cT CO ©' 00 U3 co" 

cn ■— 1 « ih n 1— 11— 1 n n h 

bj - a ,6 -' 'r ir-_r-i:- m bb+j >> 



'II 



cs cciNccnf: kfl cc os 

CN CN CN CO CM CO M 1— I 



TP0CO CC H Oi X -r - * ^ C . CD X 
M M -rr M CN M CO CN CO CN M CN u": ~ M CO 



5 Hi 2 



fit z 5? 



* 8 « 
cc S 9 



.0 - 



£5 



.2 "5 «B 2 



> > > ^ ^ > > ■_• 



. 52 



(M CO 
CO 00 CO 
CO CO ^ 



CO tJ( rj( -rf< 



to M 
CO CO 
1-1 CM 



CC^Ci-^?0-f<i— iN- r 1— W C 

OS © — CC M CO -r 1-1 CC CS I- W M 
MCOCOCO^^tP r-i 1-1 CN 



r-HCN CO ICC CC N X 

00 o 00000 

COCO CO COCOCOCOCO 



Ci o 
O rH 

CO CO 



TfU O N X C O H M ?: r ic: s 
.-iT-!r-iT-lT-tr-<CNMMMMCNCN 
CT CT CT CT CT CT CT CT CT CT CT CT CT 



THEORY AND PRACTICE OF VACCINATION 



23 



IT. 



CO CN CN CO 



o e> 3 
- ^ o 

x - S 



as x x 



T3 3 Ti 

p p £ p 

£ OQ W M 

•§ la Ph^ 3 -| 



ob'o ffl 



>> 



a s so tjo 



c3 .jy.S 

x 53 x x 



,5$ 
X 



s w 

» r 3 

"J a) 

02 X Pm 



"5 O 



ffl H N iQ ^ 
ffl N N CC 30 

00 00 CO CO OO 



1— I T 1 CO CN 

i>. to 

co co co 00 



I- I- W CO 

00 00 00 00 



CI C! O 
CO CO CS 


O 
OS 


O CN CN CN CO 
OSOOOOl 


r>. 

CO 


OO CO 00 OS 
00 00 CO CO 


CS 

CO 


OS 

CO 


OS 

00 




01 


O O rH CM 

OS CS Ci OS 


CN 

oa 


CN 
OS 


CO 


00 CO CO 


00 


x x x x cc 


00 


OO CO CO CO 


00 


co 


CO 


00 


GO CO CO CO 


00 


co 


CO 




I— < 


1— 1 1— 1 1— ! 1— 1 1— 1 


T— I 


t— 1 t— 1 r-H r— I 


I— I 








I— 1 1— 1 I— 1 I— 1 


r— ■ 


1— 1 




ffJHH 




N O O O Ci 


O 


lO CO CO r— 1 


to 




CO 


to 


kO CO rH CO 


CO 


Oi 





CN r~H 


CN 




CN 


CM CN iH 


CN 










CM 


CN 


CN 






cT cT 3 
<3 ^ x X ^ 


!-5 


<!^^<! 


+f 

m 












^' 

OS 




03 


>" 

O 


c3 

Ha 



. o 

' o ., 



. o o o 




uo o 10 o o 



to to to to 



CO to OS 
CN CN CN 



CO OS OS o o 
OS o to 1^ CO OS 
CN CO CO CO CO CO 



tO CN CO O 
'H iC CO CN 
hhhN 



CS Ci CO 
O r- O to 
CO CO CO CO 



co os 
CN (N CN 
CO CO 10 



O rH CN CO ^ O 

CO CO CO CO CO CO 
CO CO CO CO CO CO 



W CO OS o 
CO CO CO 
CO CO CO CO 



■^t* ^1 ^1 
CO CO CO CO 



O r-l 

O UO 
CO CO 



24 



THEORY AND PRACTICE OF VACCINATION 



!N 'N <N 



O CO CO 



JO 'M C CO 



J -8 

i i 
U 

■ s I s 

ill 

So 



lilili 



| | 

£ 1 is 

mill 

ill 



i 



S £ £ 53 x < 



us 



ilip 



O CM O O X> ffi CS H O (N 50 Oi <N lO CO OK O i— 1 O CO © 0^ CO 

00 go oo ccccocoo ccocco 



SS »SS 111111 ssi I 11 1111 1H 



O w c. 



t-Tco'i-T of irTvo jo^co 



If til WWJl lis I « llfl ill 



MM! 



Noom wcq cocoes cm cn 



i ii y 
hip 



i! 
I 



1 



o £ 



si- 
te ! fi 1 



o o > © 



an. 



m 



U- C<_ ^ i__ — r-*V- 



b c a s • 



t-. t» i-» i^- b» W W t>- l ^ CC CO X X GO CO 00 CO GO CC CO OS Oi o; 



ill 



ssg *S1 S SI §313 — s 



II 



11 lis §§§111 III 1 si Isss fefel 



THEORY AND PRACTICE OF VACCINATION 



25 



8 8 
cm -<t< 



3 03 



KM CO 



5 
O 
,£3 
C3 

T-H* ° 

3, •« 



c3 m 



-+-> o 



co O 

g£ i- CO 

2 2 .2 
o 72 3 

^ c3 £ 

§ g s 

p. r* a • 
H h a 



o H 



c3 cS 



GO S 
^ £ ° 

4J _ O co 35 

fr.l « § § 



08+3 c3 

CO 1— -I K 
^^^^ 

+3 p h-s> 

^ o b i-n 

GO CO GO CO 



I-H c3 
CO O 

3 ^ 



(X> 

•s ~ 

'art" 



O W .rH 
^ CO 



0. 


co 


co t-h 






O 




1— 1 1— I T-H 1— 1 i—l 


NCO OO CO 


lO T-H 


■<* 




O CD 


oc 


00 oc 






SO 


t>« J>- 00 


l>- 00 t>. CO !>. 


00 i~— cc 


00 I- 


00 


00 


00 00 


oc 


00 00 


OC oc 


00 


00 


OC 00 00 00 


00 00 00 CO 00 


00 00 00 00 


00 00 


00 


CO 


00 





O 


iH CO 


«# 


10 


N t>- N OS 


CI CO "»f J>» 


00 OS CS OS 


i-H CM 


«<# 


■<* 


00 co 


c. 


Oi cr. 


OS OS 


03 


00 


00 00 GO 00 


00 cs cs 00 00 


00 00 00 00 


os os 


OS 


OS 


00 co 


00 


oc 00 


OC 00 


OC 


00 


00 00 00 00 


00 00 GO 00 00 


00 00 00 00 


00 00 


00 


CO 


CD CM 




vO OS 


T* CM 


of 




<M~CO~tCof 


«o N co"oc"oo'"co" 


oft^ccTcT 


©TicT 


CM~ 


co" 


T-H <M 




CM CM 


CM 


CM 




i-h CM 


t-h j— 1 CM 1 — 1 CM 


T-H I— 1 CM T~H 


t-h CM 







So 

So 



4l 5 



^ § "£,+» ,d § &5) &b 6fi 

t-s ^ CO O -< <5 



Lb 3 « 
2 Is 1 



> 

: £ 
















"AOJ 






CM 


> 






















CO 









O 




a 












O 












3 




.2 







ist i 


12 




wel 















Cfr4 








"c ^ 'a 


4-3 
































































OS OS 


OS 0. 


OS 


O 


0000 


O O O T-H ,-1 




T-H I-H 


















CM 


CM CM CM CM 


CM CM CM CM CM 


CM CM CM CM 


CM CM 


CM 


CN 




OS 


CO 


CM CO 


CO 


CO 


CO 


O CO CO CM 


co co co 


Ol 'T 1^ 


O CO 


^H 


GO 




-O 


os 





^H OS 








CM O rr O O 


CO 'O. O CO 


co co 


CM 


CM 






CM 


CO CO 


CO CO 






T-H T-H CM 


(M Tfl T— 1 T-H 


t-h t-h CM CM 


CO CO 




TH 



ON GO O.O t-h CM CO lOCOl^OO CSOt-HCMCO TttlOSN CO OS O t-h 

l» n co co go 00 00 00 00 oc 00 oo c a a c c. c. o o os os o o 

COCO CO COCO COCO CO CO COCOCOCO COCOCOCOCO COCOCOCO COCO rft TJ< 



6 



THEORY AND PRACTICE OF VACCINATION 



CO CO (M O 



bp 



S U 2? 



5 J 



"2 Z> £ £ w 
.SP .13 1*1° * | § o 



Ph CO CO ^ CO CO 



9 73 B X r-. 
2 S a o o 

CO Ol, ^ § 



H CO 



t^ 
tC 72 

& & &> 



— CO ^ P-t CO CO CO Pi 



1—1 

oo oo 



oo 1— W to oo 

oo oo oo oc oo 



(MCOHCO 
tO t"— OS 
OO GO 00 00 



oo »o lO 

^ 00 00 

00 GO OO 



GO CO 
GO oo 



HON 

GO 00 00 
X X X 



w oo go go 
OO 00 GO oo oo 
OO OO GO CO 00 



GO CO CO 

oo Oi cs oi 

GO 00 00 OO 



00 © O OS 

go cn go oo 

00 OO 00 GO 



o o 

CO GO 



fN co cr. 

OiOCOC 
CO GO CO 



O I- 

05 OO 

CO 00 



,0 



C 



- a 2 ~ o 



III-? 



co^O 



^ o a a 



- »4 

«3 C ^ >j 

5*8 8* 



3 



>>co 



_ M^M HH HH 



PS rf 2 



CN CN CN CN CN CN CN 
CN CN CN CN CN CN CN 



CN CN CN CN 
CN CN CN CN 



lOWNtfi COtOO to 
t>- CI CI to CN l-H H 

i-l CO CO r-H CO CN 



Ci r-H 

CN Tt< 

CO CO 



CN CN CO 
COOON 
CO i — I CN 



CN GO 
CT. O 

CN 



CNCO rtlOCNOO CI © .— I CN CO^O 

^ ^ ^^^^^ ^ ^ ^ ^ 53^^ 



O i—i CN 
CN CN CN 



THEORY AND PRACTICE OF VACCINATION 



27 



CO 



CO CO CO 



O - 

co 73 

rH -+J 

'3 'Ph 

Si 



CO CO 

co 
CO 00 



^ 2 



*Ph 3 

3' 



« rV 



CD 
08 

I 9 

o o 
P S 



o 

r^ 

CD CD 

3 3 



.2 ^ 



CD S-S 

• ' "I CD CD r^H _ 

Pm 00 00 00 00 



CO rH 

t>. 00 

00 00 



1 S 

P ct5 

H CD 

rP £3 

0Q 00 



T3 

cd a; 



B R 



rH CD 



O o 
W> hh 
o _^ 

p s 

— CO 



c3 



OT) 5 



rU-^S cd "7. 2 tco 
00 00 £ OO hh 



? a 

S 5 
3 s 



O CD 



1? 

3 3 

CD r-l 

Ph co 

I'd 
~ g 

rB 3 

fcJO o 

co 

2 >> 



£s r 1 co 



cth jqco 

NCOOCKO 
00 00 00 00 



CD 03 > c3 =? P 
C3 CD CD CD P*. O 

Ph GO 00 CO 00 O 

CM tP TP lO TP -HH OS 

© 00 00 OO CO CO 10 
00 CO CO OO CO CO GO 



CD 
N 

'to 

CD 



a 2 



2 33 2 a 



OS CM 

00 OS 
00 GO 


TX 

os 

CO 


OO 
OO 


CD 

00 
OO 


J>. OS 

00 00 

CO 00 


O 
OS 

00 




OS 

00 


CM 
OS 

00 


OS OS t>- 00 

00 00 00 00 

OO 00 OO GO 


CO 
OS 

GO 


^ONCOCOCSCl 
OO CO CO 00 CO CO 00 
00 CO 00 00 00 00 CO 


CM 
OS 
00 


00 
00 


j-l CO 
CM i-h 


M 


kO 

CM 


00 
CM 


CO CO 
H CM 


CD 
CM 


CM 


CM 


O CO ri N 
CM t— 1 1—1 


CO 


rH GO Tp lO TP rH 
HHHW 


10 




CM 


Nov. 
June 


CD 
B 

>-a 


3 


j>> 
1-3 


■+-} -4-3 

Ph Ph 

CD CD 

00 00 


3 




3 


»J 3 

^ O ^ t-5 


< 


> fn" CD A > 

O 3 CD 2 OS CD 


00 


<i 


X>- CM 
CO CO 


TP 
CM 


CM 


CO 


CD lO 
CO CO 


CO 


CO 
CO 


OS 

01 


>0 CD tP OS 
tP CO CO tP 





CM C TP CO tP iO CM 
iQ m CO CO M CO 10 


"Hi 


OS 
CO 




CO i^. 
CM CO 



CM OO 
rH ITS 
rH CM 



OO O CO CD O 
CD TP CO lO ^ 
CO CM CM rH 



TP" CD OO VO OS TP 
CSCOCOON 
rH rH CM CM 



>C CO 
CM CM 
TP TH 



O rH CM CO 
CO CO CO CO 
TP "^H tP 



0©NCO 
CO CO CO CO 



O rH fM CO TP kO CD 



THEORY AND PRACTICE OF VACCINATION 



2 
f 

\ t 
lit II :! | 



MM sill I 



1 



lip 



rtii 



JIM 



III llli I 



III llll 



v- - •_• _• e^H ^ > e,.: 



Hi 



2? S3 SSSS'fe £ 



Jii 



5 S 1«S5 I 



I 
1 



2 I II 



3V I 



Pi 



THEORY AND PRACTICE OF VACCINATION 29 



Table VII. 



ACl 111 1 1 X G (J. 1 J T 

unvaccinated. 


Stated to 
have been 
vaccinated, 
but having 

no scars. 


Having 
1 scar. 


Having 
2 scars. 


Having 
3 scars. 


4 scars. 




Having 
5 or more 
scars. 


Days. 


Days. 










3 












3 












7 






... 






14 










21 


21 










28 










... 




35 














42 












42 














42 














42 














42 




... 










49 














61 


61 












63 








... 






90 


90 












91 


91 












106 


92 












122 








... 






122 


152 












182 














182 














182 








... 






183 














183 








... 






183 














213 














213 














274 














274 












275 












304 












OUi 












304 














335 














335 














Years. 


Years. 














1 












1 












1 












1 












1 




... 








1 












1 






j 



3° 



THEORY AND PRACTICE OF 



VACCINA TION 



Admittedly 
unvaccinated. 


Stated to 
have been 
vaccinated, 
but having 

no scars. 


Having 
1 scar. 


Having 
2 scars. 


HaviDg 
3 scars. 


Having 
4 scars. 


Having 
5 or more 
scars. 


Years. 


Years. 


Years. 










1 


1 












1 














1*16 














1"33 














1-5 


V5 












1-5 


1-5 










... 


1*83 


1 -5 












2 


2 


2 










2 


2 










■■• 


2 


2 












2 


2 


... 










2 


2 










"' 


2 

2 


2 












2 














2 














2 




... 










2 














2 












... 


2 














2 














2 














2 














2 














2 














2'5 


2'5 












2-5 


2-5 












2'5 














2'83 














3 


3 












3 


3 












3 


3 












3 


3 












3 


3 












3 


3 












3 

3 














3 














3 














3 














3 














3 














3 














3 














3 














3 














3 














3 














3 

35 


... 
... 


i 

... 









THEORY AND PRACTICE OF VACCINATION 31 



Admittedly 
un vaccinated. 



Years. 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 

4-5 

5 
5 
5 
5 
5 
5 
5 
5 
5 
5 
5 
5 
5 
5 
5 
5 



Stated to 
have been 
vaccinated, 
but having 

no scars. 



Years. 
4 

4 
4 



Having 
1 scar. 



Years. 



Having 
2 scars. 



Years. 




Having H-ing 



32 THEORY AND PRACTICE OF VACCINATION 



1 

Admittedly 
unvaccinated. 


Stated to 
have been 
vaccinated, 
but having 

no scars. 


Having 
1 scar. 


Having 
2 scars. 


Having 
3 scars. 


Having 
4 scars. 


1 

Having 
5 or more 
scars. 


Years. 


Years. 


Years. 


Years. 


Years. 


Years. 


Years. 


/ 


7-5 












8 


8 


'8 










8 


8 


8 










8 


8 












8 


8 












8 


8 












8 


8 












8 


8 












8 
8 


8 












8 














9 


9 




9 


9 






9 


9 












9 


9 












9 


9 












9 














9 






9-5 








10 


10 




10 








10 


10 












10 


10 












10 














10 


10 






10 






10 














10 














10-5 














11 


11 


11 


ii 








11 




11 










11 














11 














11 








11-5 






12 


12 


12 


12 


12 


12 




12 


12 




12 


12 


12 




12 


12 




12 








12 


12 












12 


12 












12 


12 












13 


13 


13 


13 


13 


13 


13 


13 




13 




13 






14 


14 


13 


14 


13 






14 


14 


13 


14 


13 






14 


14 


13 




14 


14 


16 


14 


14 


13 










14 


14 


14 










14 




15 




15 


15 




15 


15 


15 




15 






15 


15 


16 




15 






15 


15 


16 


16 


16 


16 


16 


15 


15 


16 


16 


16 






16 


15 


17 




17 






17 


16 


17 




17 1 ... 





THEORY AND PRACTICE OF VACCINATION 





Stated to 












Admittedly 
unvaccinated. 


have been 
vaccinated 
but having 
no scars. 


Having 
1 scar. 


Having 
2 scars. 


Having 
3 scars. 


Having 
4 scars. 


Having 
5 or more 
scars. 


Years. 


Years. 


Years. 


Years. 


Years. 


Years. 


Years. 




16 


17 




17 




17 




16 














16 














17 












18 


18 


17 


18 


19 


18 


19 


18 


18 


17 


19 


19 


19 


21 


19 


18 


18 


19 


19 


21 


21 


20 


19 


18 


19 


20 


22 


21 


21 


21 


18 


20 


20 


28 


22 


21 


22 


19 


20 


20 


34 


27 


22 


24 


20 


21 


21 






22 


24 


20 


21 


22 






23 


26 


22 


22 


22 






25 


29 


24 


22 


23 






26 


33 


24 


22 


25 






27 


34 


24 


26 


27 






27 


38 


24 


26 


29 






30 




25 


27 


30 






30 




27 


27 


30 






36 
36 




29 
30 
30 
30 
30 
34 
37 


28 
33 






... 


looZ 


VfDZ D'± 


OOO 




oy-i o 




1 oo 


210 cases, 


105 cases, 


47 cases, 


31 cases, 


33 cases, 


12 cases, 


10 cases, 


average 


average 


average 


average 


average 


average 


average 


= 6*58 


= 9-07 


= 17-77 


= 17*82 


= 18-02 


= 18-67 


= 19-3 


years. 


years. 
9-86* 


years. 


years. 


years. 


years. 


years. 



The more reasonable opponents of vaccination admit the 
decrease of small-pox at the present time, but explain the 
decrease in two ways. They say, first, that improved 
sanitary conditions have occasioned it. We will admit that 
to a very limited extent this is true, but if it be the main 
reason then surely the other zymotic diseases should also 
have declined in some such way as small-pox. From 
Table V. it will be seen that, instead of decreasing, they 



* This lower figure is the corrected age. (See p. 9.) 

3 



34 THEORY AND PRACTICE OF VACCINATION 



seem to have absolutely increased, moreover in the one 
disease, whose death ages are analyzed by Dr. Percival in 
the last century, viz., measles. See Table VIII. 

Table VIII. 

AGE AT DEATH FROM MEASLES AT MANCHESTER, FROM 1760 TO 
1774, COLLECTED FROM THE REGISTER OF THE COLLEGIATE 
CHURCH. 



Age 
0-1 


Age 
1-5 


Age 
5-20 


Age 
20-40 


Age 
40-60 


Age 
60-80 


15 
16-48 


72 
79-12 


4 
4-40 












We see that 95*6 per cent of individuals who died of 
measles were under 5 years of age in the last century. 

Table IX. 

AGE AT DEATH FROM MEASLES IN LONDON DURING THE PERIOD 
1890 TO 1894. 



Age 


Age 


Age 


Age 


Age 


Age 


0-1 


1-5 


5-20 


20-40 


40-60 


60-S0 


2,747 


9,916 


751 


28 


2 


1 


20-43 


73-75 


5-59 


•21 


•02 


•007 



From Table IX. we see that 94*18 per cent, deaths from 
measles take place at the present day in children under 
5 years of age ; in fact, very nearly the same as in the last 
century — a very different state of things from what we have 
seen to be the case with small-pox. 

That to have had small-pox in infancy was as common 
in pre-vaccination times as it is at the present day to have 
had measles in infancy, may be inferred from the condition 
of things in Ware.* At the time we are speaking of, viz., 
1722, Ware was only a village with a population of 2,515. 

* See a paper in the library of the Boyal Society, England. 



THEORY AND PRACTICE OF VACCINATION 35 



The registrar divided the population into three classes. 
The first class contained those who had had small-pox in 
a previous epidemic. They numbered 1,601 cases. The 
second class contained those who had small-pox during the 
then present epidemic, and these numbered 612, of which 
72 died, leaving 540 alive. Therefore there were living, 
after the epidemic, 2,443, of which 2,141 had had small- 
pox, or 88 per cent., and the third class were contained 
under the heading of those who have to have their small-pox. 

We may hence infer that 88 per cent, of the population 
of Ware, after the epidemic of 1722 were more or less 
pitted with the small-pox. At the present time, walking- 
through the streets of London, we have counted 3,720 
people passing by, and of these only 9 were obviously 
scarred, or '24 per cent. 

Some little explanation might here be given of the 
methods by which Table V. has been compiled, for 
an apparent inconsistency may to some extent be ex- 
plained. 

Deaths from small-pox prior to the year 1838, which was 
the first year that the Eegistrar-General's Eeports were pub- 
lished, containing as they did certificates of death from 
registered medical practitioners, deaths from small-pox and 
other diseases were previously collected from certificates 
which the law compelled to be given before the body of the 
deceased could be buried. These certificates were given by 
persons whom the guardians of the poor appointed. They 
were called 'Searchers,' and it was their duty to inspect 
every dead body, and to give a certificate, as far as they 
were able, as to the cause of death. These certificates were 
sent weekly by the parish clerks, who received them on the 
burial, to the Company of Parish Clerks, and this company 
were thus able to issue a weekly publication, which went 
by the name of the Weekly Bills of Mortality. These bills 
were summarized yearly, and the summarized bills were 
called the General Bills. 

The ' Searchers ' were not medical practitioners ; indeed 

3—2 



36 THEORY AND PRACTICE OF VACCINATION 



they were often the poorest people in the parish, for it was 
anything but a pleasant occupation to visit the bodies of the 
dead, especially those who had died of infectious diseases. 
The following quotations from old authors will show what 
has just been stated of them is correct. 

From John Graunts, F.R.S., Bills of Mortality, published 
in 1676, p. 34. 

'In the next place it shall be examined under what 
name or cassualty such as die of these diseases are 
brought in ; I say, under the Consumption ; foreasmuch as 
all dying thereof dye so emaciated and lean (their Ylcers 
disappearing upon Death) that the Old-women Searchers, 
after the mist of a cup of Ale, and the bribe of a two 
groat* fee, instead of one given them, cannot tell whether 
this emaciation or leanness were from a Phthisis or from an 
Hectick Fever, Atrophy, etc., or from an Infection of the 
Spermatick parts which in lenghth of time and in various 
disguises hath at last vitiated the habit of the Body and by 
disabling the part to digest their nourishment brought them 
to the condition of leanness above mentioned.' 

Dr. Fothergill, quoted by Willan in his miscellaneous 
works, edited by Ashby Smith, M.D., 1821, ' Observations 
on the Weather and Disease,' p. 196. 

Dr. Fothergill was of opinion that the number of deaths 
from Consumption was greatly over-rated in the Bills of 
Mortality ; he remarks on this subject " Foreigners who 
are ignorant in what manner our Bills are compiled give it 
out that Consumption is the grand endemic of England. 
The Searchers are commonly two (sic) as poor and ignorant 
persons as the Parish affords ; these are to see all dead 
bodies and to report to the Company of Parish-clerks of 
what disease they died ; if the body is emaciated, which 
may happen even from an acute fever, it is enough for 
them to place it to the account of Consumption though the 
death of the part} 7 was perhaps owing to a disease specifically 
different ; and thus a monstrous account is framed by the 

* A groat = fourpence. 



THEORY AND PRACTICE OF VACCINATION 37 



ignorance of the searchers, to the disgrace of our country 
and even so far as to discourage some foreigners from coming 
among us." ' 

It will be readily inferred how frequent errors of diagnosis 
must have been. However, the disease most easily recog- 
nised was small-pox, and fewest mistakes would there- 
fore be registered under this disease. That the Bills of 
Mortality did not in fact over-estimate the deaths from 
small-pox may be inferred from the registration of disease 
in 1838 and 1839, for we have the registration both of the 
Bills of Mortality and the Registrar-General. We find that 
for 1838 the Bills of Mortality give 788 deaths, whereas the 
Registrar- General gives 3,817 deaths, but the Registrar- 
General's records embrace districts outside the Bills of 
Mortality. Now we know nearly what districts outside the 
Bills of Mortality contributed. They were as follows : 

Kensington ... ... ... ... ... 253 

Marylebone 199 

Pancras (including Small-pox Hospital) . . . 372 

Camberwell ... ... ... ... ... 23 

Greenwich ... ... ... ... .. 129 

One-third of Poplar to represent St. Leonard, 

Bromley, and St. Mary, Stratford-le-Bow. . . 23 
One-tenth of Hackney to represent St. Mary, 

Stoke Newington ... 7 

1,006 

Hence, if we deduct this number from the Registrar- 
General's figures, 3,817-1,006 = 2,811, this ought to tally 
with the number of deaths recorded by the Bills of Mortality, 
but it is in fact 2,023 in excess, or the Bills register 257 per 
cent, too little small-pox. There is another reason to suspect 
that the Bills of Mortality in London under-estimated the 
deaths from small-pox, and that is, on referring to Table V., 
p. 34, it will be seen that the average small-pox deaths was 
higher in Kilmarnock, a then village in the south of Scot- 
land, than it was in London. As the registration was dif- 



38 THEORY AND PRACTICE OF VACCINATION 



ferent from what it was in London, the apparently higher 
death-rate in Kilmarnock may be more than accounted for 
by the errors of registration in London. 

Death is the worst evil that can befall us, but there is one 
nearly as bad, and that is blindness. The blind institutions 
of the last century used to receive their greatest contingent 
from unfortunate people who had lost their sight from 
small-pox. Sir Gilbert Blane quoted a report of the Hospital 
for the Indigent Blind to the effect that two-thirds of those 
who applied there for relief had lost their sight by small- 
pox.* 

Dr. Gregory, the superintendent of the Small-pox Hospital 
in 1819, writes, that a large proportion of the blind have 
been found to owe their misfortune to the secondary fever of 
small-pox. 

Mr. Cross, writing of the epidemic of small-pox at Norwich 
in 1819, states that of 200 cases of small-pox, 3 had lost 
eyes from small-pox, or 1*5 per cent. 

In the present day, a statement of the Christian Blind 
Belief Society (established in 1843) contains the names 
of fifty people seeking relief, blind from all causes. One 
of these people was blind from having had small-pox, 
viz., Sarah Barnes, Bethnal Green, aged 39. Small-pox 
hence appears to occasion 2 per cent, of the blindness at 
the present time. The date of the advertisement is about 
1888. A copy of the statement is appended, p. 39. 

Dr. Brailey has also noticed the vaccination scars of 
fifteen cases of people who had lost an eye from small-pox, 
and he found that seven were admittedly unvaccinated when 
they had the small-pox which blinded them. These cases 
were 16 out of 763 who lost eyes from all causes, which 
shows, as far as it goes, that 2*24 per cent, of the blindness 
at the present time is caused by small-pox. (See p. 40.) 

* Medico-Chirurgical Transactions, vol. x., p. 826. 



THEORY AND PRACTICE OF VACCINATION 



J) 



Statement of the Christian Blind Belief Society. 



Candidates. 



1. Mitchell, Wm. H. ... 

2. Smith, Stephen 

3. Brady, Elizabeth 

4. Sandiforth, Harriett . . . 

5. Rham, Elizabeth 

6. Ballinger, Harriett ... 

7. Barnes, Sarah ... 

8. Willard, Richard 

9. Lamb, Mary ... 

10. Chatfield, Albert Edw. 

11. Brown, John ... 

12. Bayley, Charlotte 

13. Wilkinson, James 

14. Berry, Ellen 

15. Perrigo, Francis 

16. Harding, Thos. 

17. Goodchild, Augusta . 

18. Savage, Christopher .. 

19. Lee, Alice A. H. 

20. Hadkinson, Eliz. 

21. Kelynack, Charlotte .. 

22. Lucas, Grace ... 

23. Bush, Fanny ... 

24. Edwards, Edith 

25. Franks, Hy. Wm. 

26. Dutnall, Mary A. 

27. Cadman, Eliza 

28. Winterton, Geo. 

29. Burley, Wm 

30. Walker, Maria 

31. Hay ward, James 

32. Smith, Eliz 

33. Ponshaw. Hy. 

34. Puddefoot, Daniel .. 

35. Flipping, Emma 

36. Silvester, Emma 

37. Poynter, Emily 

38. Parkes, John ... 

39. Jennings, Geo. 

40. Smith, James ... 

41. Jaggers, Thomas 

42. Brookes, Thos. 

43. Bennett, Alfred 

44. •Gaylor, Susan .. 

45. Lawrence, Sarah 

46. Nicholes, Wm. 

47. Brassington, H. 

48. Foster, Emma 

49. McCullum, Fanny . 

50. Cosker, Thos 



Age. 


Address. 


Cause of Blindness. 


56 




Westerntown, Sidmouth 




Disease of brain. 


80 


St. Leonard's-on-Sea ... 


Cataract. 


36 


Darlington 


Inflammation. 


33 


Kippax, Leeds ... 


Glaucoma. 


46 


Wisbeach 


Detachment of retina. 


48 


Minsterworth 


Cataract. 


39 


Bethnal Green ... 


Small-pox.* 


74 


Silverhill, Hastings 


Cataract. 


64 


Shepherd's Bush 


Cataract. 


51 


Stoke-on-Trent ... 


Fits in infancy. 


62 


Norwich ... 


Inflammation. 


67 


Tottenham Court Road. , . 


Cataract. 


55 


Kentish Town ... 


Typhus fever. 


43 


Drury Lane 


Typhus fever. 


78 


Leominster 


Cataract. 


84 


Dursley, Gloster 


Unknown. 


39| 


Wells, Somerset 


Disease of bram. 


56 


St. Luke's, E.C. 


Yellow fever. 


20 


Mile End 


Measles. 


51 


Battersea 


Effects of a blow. 


32 


Penzance... 


Illness. 


68 


Haggerston 


Cataract. 


46 


Chichester 


Constitutional. 


25 


Chelsea ... 


Atrophy of the nerves. 


28 


Canterbury 


Born blind. 


53 


Maidstone 


Inflammation. 


45 


Wolverhampton 


Cataract. 


65 


Ware 


Cataract. 


32 


S. Lambeth 


Failing of optic nerve. 


71 


Maida Vale 


Glaucoma. 


53 


Ryde, I.W 


Constitutional. 


19 


Abbenhall 


Hereditary. 


35 


Southampton 


Water on the brain. 


69 


Hemel Hempstead 




30 


Camden Town ... 


Tumour on the brain. 


43 


Bristol 


Abscess on brain. 


39 


Orleton ... 


Inflammation. 


46 


Stoke Ferry 


Disease of nerve. 


38 


Bow 


Cold. 


50 


Newmarket 


Scrofula. 


33 


Barking 


Born blind. 


42 


E. Greenwich ... 


Lead colic. 


35 


Bethnal Green 


Constitutional weak- 






ness. 


. 39 


Hatfield 


Born blind. 


. 55 


Preston ... 


Disease of the optic 






nerve. 


. 50 


Poplar 


Retina destroyed. 


. 58 


Leek 


Inflammation. 


. 72 


Stratford 


Unknown. 


. 43 


Poplar 


Weakness. 


. 73 


Limehouse 


Sudden strain. 



* Showing that, according to this statement, small-pox even now occasions 
2 per cent, of the whole total blindness. 



THEORY AND PRACTICE OF VACCINATION 



© N H © 

OO OO OO CO 



H0050NCM03 <T> 

OOOOCOOOGOCOCOCO coco 



CO (N 1-1 H O r-l 

CO CO CO CO CO GO 

co co co cc co oo 



|c g ~ o 



00 W 

1 - 00 

oo co 



•uoi^Aaasqo 
jo aj«p 
^uati'Bd jo oSy 



B § 



^ ^ & « .3 s s 



Pi 



; c c .5 



^3 o 



T3 o a> o 

pHHH 



09 09 02 09 09 09 GQ 

S 3 ?e e8 c3 3 3 
o © o © © © © 

>> ^ !>> >> >> >> 

'(NmicNoioio 



« h n x a c: x x -m X) 

05^TiO^C000<X>C5 (NO 



r^oo on O 



LECTURE II. 



HISTOLOGY OF THE VACCINE AND SMALL-POX VESICLES. 

To-day, gentlemen, I have to call your attention to the 
morbid anatomy of vaccinia and to that of small-pox, and I 
hope to establish in your minds the close anatomical changes 
which hold between these morbid conditions — in fact, I 
may say, establish their identity so far as their morbid 
anatomy is concerned. I shall also step over our strict 
boundary to say a few words about the morbid anatomy of 
chancre, and I hope to be able to show you how utterly 
different are the minute changes which take place during 
the development of the syphilitic chancre. I should not 
have alluded to this last-mentioned disease if it had not 
been recently affirmed by a gentleman, who is essentially an 
anti-vaccinator, though, I believe, he does not admit as 
much. Dr. Crighton is referred to. He implies that every 
vaccination vesicle is a lesion of a syphilitic nature. 

Before we enter upon a discussion of the morbid changes 
which take place after vaccination, it may be convenient to 
review the normal histology of the special seat of lesion, 
viz., the skin, and I shall adopt Dr. Klein's nomencla- 
ture. 

First, then, we find the external cuticle, epidermis, or 
scarf-skin ; this layer is called by Klein the stratum corneum. 
(See Plate I., a.) It is that portion of the skin which is 
raised from the rest when a blister is applied. It is also 



42 THEORY AND PRACTICE OF VACCINATION 

that part which becomes detached when the dead skin is 
macerated, as when the body of a man has been in water a 
week or two, or the foetus has suffered intra-uterine death and 
not been shortly expelled. Immediately below this may be 
seen the stratum lucidum ; it is a thin homogeneous layer, 
the component cells of which are only indistinctly seen in 
some sections, and the nuclei have disappeared. (See 
Plate L, b.) 

The next layer is the granular layer of the rete Malpighii 
(Langerhaus). It consists of flattened cells, with a nucleus 
and granules. The granules are chiefly to be seen at the 
poles of the nucleus, gradually diminishing in size as they 
extend outwards. (See Plate I., c.) 

The next layer of the rete Malpighii (see Plate L, d.) is 
a more or less stratified layer, of which the more superficial 
cells are flattened together with their nuclei. In the suc- 
ceeding layers the cells and their nuclei are rounder. The 
cells are connected with each other by fine filaments, the 
so-called prickle cells (Max Schultze). (See Plate L, a, 
Fig. 2.) Lastly, in the deepest layer the cells are columnar, 
with oval nuclei. These latter rest upon the cutis vera or 
corium. (See Plate I., e.) 

Thus far only need we minutely describe the epidermis. 
The pathological changes which take place after a success- 
ful vaccination are : first, there is an increase of intercellular 
fluid, especially between the round epithelial cells of the 
rete Malpighii, probably on account of this increase of the 
fluid or nourishing material ; you have an increased forma- 
tion of cells, and an increase in size of individual cells. 
These three increases, viz., the increase of the intercellular 
fluid, the increase in the formation of cells, and the increase 
in size of many of the cells, together constitute the hard 
red papule, which feels like a shot underneath the skin. 
This stage is called the papular stage. The papule grows 
in area, encroaching more and more on the healthy skin 
centrifugally, while in the centre, owing to the large amount 
of intercellular fluid and the rupture of some of the large 



PLATE I 



Z. Strcuturrv TjuaxloLuwo. 

3, Svope^fLcLoiL layer of reie- malp hg "hvuL irixduxLuruj grocruxLocr oell 
layer. 

4-, MvcLdLe- Zccyei- o f -rate- mxikp i^g InAx-. 
5>D&ep layer* of do. 




Homdredtks and Tentlas of a. Millimetre 



West, l\ f e v» man clrromo . 



PLATE' la,. 




PLATE II 




West,lTewman. cTaromo 



HISTOLOGY OF THE VACCINE DISEASE 43 



cells, vacuoles, as they have been called, are formed. They, 
however, are full of the vaccine lymph. (See Plate L, a, 
Fig. 3.) Some of the cells do not burst, but are more or 
less distorted from, pressure and tension, becoming spindle- 
shaped. These elongated cells, lying in juxtaposition with 
one another, form the walls of the vacuoles, and are, in fact, 
the dissepiments of the vesicle, for the vaccine vesicle is not 
like a pustule, from which, when pricked in one place, all the 
pus can be extracted from this one opening. Not so, however, 
the vaccine vesicle ; for this must be pricked in many places, 
on account of these dissepiments, before much lymph can 
be obtained. The vaccine vesicle is more of a honeycombed 
structure rather than a pouch. (See Plate L, a, Fig. 3.) 
These changes take place first at the site of vaccination, 
and, as I have said, gradually extend outwards, the newly- 
invaded portion of the skin going through the same changes 
as did that of the centre ; but as the vesicle extends outwards 
other changes take place at the centre. The vacuoles here, 
at first large, become smaller, cell growth ceases, and the 
enlarged cells begin to shrink, so that if a section be made 
at this stage of the vesicle's growth on a plane parallel with 
the surface of the skin, it will have the appearance repre- 
sented in Plate II. 

The ordinary description of the vesicle consisting of 
radiating dissepiments, like those of an orange, is quite 
imaginary, for there is really no regularity about their 
deposition. It is true the vacuoles in the centre, or those 
which were first formed, are smaller, from absorption 
of the fluid, than the later formed ones at the circum- 
ference, and this may have given systematists the idea that 
the vesicle consists of radiating divisions. And, further, the 
puckered condition of some vaccine scars may have confirmed 
this impression ; but the puckering of the scar, when it exists, 
is not from the remains of these fanciful radiating dissepi- 
ments, but from the severity of the inflammatory progress 
of the disease, the whole thickness of the skin having been 
involved, and the consequent contraction of the resulting 



44 THEORY AND PRACTICE OF VACCINATION 



cicatrix. The formation of these vacuoles, as we have 
described, continues until the vesicle has finished enlarging, 
and this stage of the development of the vesicle we may 
call the vesicular stage. Before, however, the vesicle has 
quite ceased to grow, an inflammation of the skin adjacent 
to the vesicle begins to appear, first immediately round the 
vesicle, and generally extends when at its height to more 
than an inch in extent around the vesicle. This inflamma- 
tion or areola, as it is called, usually begins early on the 
eighth day, and may begin earlier if the vesicle be advanced, 
or later if the vesicle be retarded, or may even scarcely appear 
at all, if the child has taken mercury some days before and 
continues taking it during the course of vaccination. Hence, 
a total absence of all areola on the eighth day is to be 
looked upon with suspicion. This areola is at its height on 
the tenth day after primary vaccination, and then begins to 
decline. At this stage of the vesicle a second or new stratum 
lucidum begins to form (Plate III., c), at first at the margins 
of the vesicle, and subsequently over its whole area. The 
old stratum lucidum forms the external-limiting membrane 
of the vesicle, for the stratum corneum is generally shed 
and separates from the stratum lucidum, leaving this, as 
we have already said, the external limiting membrane. 
The new stratum lucidum forms over the bottom of the 
vesicle. It is really the beginning of the process of heal- 
ing, and is, in fact, the first formation of the new skin 
beneath the vesicle, and all the tissues between the two 
strata lucida dry up and constitute the thick dark scab 
which forms over the site of vesiculation. This is the reason 
why, after vaccination, the scab that forms is so thick. 

If nothing is placed on the wound to prevent the scab 
drying up as it naturally should, and the healing process 
goes on uninterruptedly, then when the primary scab falls, 
which it normally does on the twenty-first day after vaccina- 
tion, a sound surface to the previously diseased skin presents 
itself ; but if the primary scab should be removed by a 
poultice or other means before the process of healing has 



PLATE III 




Tenths and Hundredths of a Millimetre x!12. 



HISTOLOGY OF THE VACCINE DISEASE 45 



sufficiently taken place, then a moist surface remains 
through which the humours of the body find exit, and 
drying, by reason of the warmth of the body, secondary 
sulphur scabs form in the place of vesiculation, and if 
these be removed by poultice an ulcerated place is found. 
This ulceration may extend a considerable depth, even right 
through the skin. This condition is more often seen when 
the vesicles have been subjected to maltreatment after 
vaccination with animal lymph than it is after like mis- 
treatment with human lymph, although I have seen similar 
conditions after the use of either. The rule for treatment, 
therefore, is never to apply a poultice or wet or oiled rag 
until the normal areola has abated, which it normally does 
during the second week. If the primary scab has been re- 
moved either by maltreatment or otherwise, and the wound 
is covered by the secondary sulphur scabs, then a poultice 
may be applied to remove these — a warm bread-poultice is 
the best — and after this removal a piece of clean linen rag, 
on which is lightly spread some zinc ointment, may be 
applied to the wound. This should be changed every 
morning and night. Mercurial ointments should not be 
used : they almost invariably irritate the wound and thus 
prevent its healing. Let me also here caution you against 
the use of ' vaccination shields ' ; these might be proper if 
changed once a day, but otherwise they may become soiled 
with the discharges from the vesicle and are replaced with 
all their filth day by day ; and, moreover, the uneducated 
class lend their shields to one another, and if not, put them 
by for a future occasion. What is more likely to produce 
septicaemia than the use of such articles? It is well to 
cover the part with a dry, clean linen rag, and to change it 
once or twice a day. 

Now, the minute morbid anatomy of the skin when 
affected by small -pox is exactly as I have described it 
when vaccinated. You have the same stages of papula- 
tion, of vesiculation, and inflammation, and the same 
structures affected. (See Plate IV.) The small-pox vesicle is 



4 6 



THEORY AND PRACTICE OF VACCINATION 



generally umbilicated in the centre (see Plate IV., Fig. 1), 
and a hair follicle usually is present at the centre of this urn- 
bilication, as seen in Plate IV., Fig. 1. Some have been led 
to think that the hair follicle is the cause of the umbilication. 
There are several reasons, however, why we should hesitate 
to accept this explanation. First, because the umbilication 
takes place also in those parts of the skin which have no 
hair follicles, e.g., the palms of the hands and soles of the 
feet. Secondly, because a vesicle never has more than a 
single umbilication, although covering an area having a 
plenitude of hair follicles. Thirdly, in inoculated small- 
pox it is the site of the initial inoculation which forms the 
umbilication, and if the inoculation be done in a line the 
umbilication of the inoculated vesicle forms in the centre 
of this elongated vesicle. 

We are therefore led to think that the hair follicle really 
is not the cause of the umbilication. The reason probably 
will be found in the fact that the capillaries round the hair 
follicles are a little smaller than in other parts of the skin, 
and thus the germs of the disease are arrested in them 
more frequently. They thus form the centres from which 
the vesiculation takes place, and correspond with the centre 
from which the inoculated vesicle arises. This view will 
also help to explain why in small -pox you occasionally get 
more numerous vesicles over those parts where there is 
constant pressure before patients take to the incumbent 
position in bed. I have seen a distinct line of vesicles just 
below the knee on a woman. This was the part where she 
used to wear her garter. I have also seen the same con- 
dition on a man's shoulders, two strips of more closely 
placed vesicles where the pressure of the braces has been. 

The microscopical appearance of the skin of the arm, 
due to the morbid condition set up by the development of 
a syphilitic chancre, is entirely different from that I have 
just described as due to vaccine. No vesiculation takes 
place either of the middle layer of the rete Malpighii, or, 
indeed, any vesiculation at all. There is a great prolifera- 



PLATE 



IV. 




HISTOLOGY OF THE VACCINE DISEASE 



tion of small cells, which are best seen in the cutis vera 
and in the tissue immediately below this. These increase 
in number, extending upwards, and seem to crowd out the 
normal cells of the rete Malpighii until they reach the 
surface. The stratum corneum becoming detached from 
its normal bed, strips off, and you thus have left a secret- 
ing surface formed of the small round cells which have 
crowded out the normal cells of the rete Malpighii. From 
the micro-photograph (Fig. 2, Plate IV.) it may be judged 
how entirely different this morbid process is to that which 
occurs after vaccination. See Fig. 3, Plate IV. To borrow 
terms from botanical science, we might describe the syphi- 
litic chancre as an endogenous, and the vaccine vesicle as 
an exogenous, growth. Hence we see the chancre and the 
vaccine vesicle have not even an anatomical relation. The 
only one they indeed have is linguistic, for one is called the 
small-pox and the other, in common parlance, is called the 
great-pox. If this be the association of thought, it recalls 
to our mind the doctrine of signatures of the last century. 
One example will suffice to explain this. The white 
meadow saxifrage (Saxifraga granulata), with its kidney- 
shaped leaves and their peculiar spotted surface, has a sort 
of likeness to the human lung ; therefore the physicians of 
that day considered it a curative for lung diseases, accord- 
ing to the then prevailing doctrine that plants which repre- 
sented in some sort of fashion various organs of the body 
were good for the disease of those organs they were sup- 
posed to resemble. This theory was called, therefore, ' the 
doctrine of signatures.' 



LECTURE III. 



THE DIFFERENCE BETWEEN A PRIMARY AND A SECONDARY 
VACCINATION. 

We will now consider the difference between a primary 
vaccination and re-vaccination. 

Let us consider a primary vaccination represented by a 
straight line. At one end of the line we will suppose that 
we are not as yet vaccinated, and this point we will mark 
as zero ; at the other end of the line we will suppose that 
we are fully vaccinated, and this point we will mark 9. 
Let us now divide the line to 9 into nine equal parts, 

I I I I I I J I I I 

012345 6789 

so that each division may represent the amount of modi- 
fication the system undergoes during each day of vaccina- 
tion. 

We have performed the two following experiments, which 
we will detail here, as they will help us to understand the 
appearances of re- vaccinations. 

The first experiment was : instead of putting all the 
vesicles on the arm at the time we first vaccinated it, 
we have put on only one ; the next day we put on another, 
and so on until the tenth day, and in both cases which 
we had the opportunity of so vaccinating we found that the 
ninth day was the last day we could produce any specific 
effect from the vaccination. It was curious to observe 



PRIMARY AND SECONDARY VACCINATION 49 

how the vesicles that were subsequently put on to the first 
developed. We will take that vesicle which was vaccinated 
four days after the first as an example. This vesicle 
arrived at its maturity five days after it had been in- 
oculated, or on the ninth day from when the first had been 
inoculated. Moreover, it hurried through its stages, over- 
taking gradually the first vesicle, and both maturing 
together on the ninth day. That vesicle which was in- 
oculated on the seventh day reached its maturity also on 
the ninth day from when the first vesicle was inoculated, 
or the second day from which it had been inoculated — in 
fact, all the vesicles matured on the ninth day from which 
the first had been inoculated. After the ninth day no 
further specific effect could be produced by inoculation of 
vaccinia. 

M. Trousseau, on p. 121, vol. i., of his fourth edition of 
' Clinique Medicale,' describes himself as having made 
similar experiments with the same results, and we know 
from Mr. Bryce as long ago as 1809 that this phenomenon 
had been observed, for on p. 173 of his book the following 
passage will be found : ' That if during the regular progress 
of cow-pox a second inoculation be performed a certain 
number of days after the first, the affection produced by 
this second inoculation will be accelerated in its progress 
so as to arrive at maturity, and again fade, at nearly the 
same time as the affection arising from the first inocula- 
tion, and that this will take place although the constitu- 
tional affection be so slight as otherwise to pass unnoticed.' 
In passing we may observe also that the same observation 
had been made with regard to the vesicle produced by the 
inoculation of small -pox — another piece of undesigned 
evidence of the close affinity of the two diseases. See p. 159, 
et seq., ' Practical Observations on the Inoculation of Cow- 
pox,' by James Bryce, published in 1809. 

The second experiment was : supernumerary fingers were 
vaccinated on the tip, and the finger removed on different 
days after vaccination. 

4 



5o THEORY AND PRACTICE OF VACCINATION 



For instance, one child was vaccinated on the tip of its 
finger, and the finger, together with the vaccine vesicle, 
was removed on the fourth day from the time it had been 
vaccinated.* About a month after the child was again 
vaccinated on the arm. The second vaccination ran rapidly 
through its course, reaching its maturity on the fifth day, 
and then began to decline. And it was further found in 
other children who had supernumerary fingers that, if the 
finger with the vaccine vesicle was removed on the second 
day after vaccination, then the subsequent vaccination per- 
formed a month after the stump had healed ran seven days' 
course. In the former case four and five make nine, and 
in the latter two and seven make nine. All the super- 
numerary fingers obeyed the same law, which was that, 
on the assumption the vesicle took nine days to mature, 
the sum of the times of the two vaccinations always equalled 
nine days. Let us look at the subject in a different light. 
We will suppose that during the growth of the vesicle a 
certain product is given off from . it, and that when the 
system is saturated with this product, it is rendered in- 
capable of further supporting the vesicle, therefore the 
disease terminates ; but if we remove the vesicle before this 
saturation has taken place there remains something short 
of saturation, which condition is not incompatible with a 
further growth of the vesicle. Hence, if the vesicle should 
be removed at any time before its full development, there 
will remain in the system a capacity of a vesicle growing 
until saturation occurs. As we wish this idea to be fully 
realized, let us look at it from still a different point. We 
will suppose the vesicle to consist of nine definite concentric 
circles, one circle for each day's growth, and that each 
circle is inoculated by its interior adjacent circle. Now, 
if we remove the vesicle before its full development, then, 
prima facie, there must remain so many circles to be com- 
pleted before saturation occurs. In other words, by removal 

* Paper by the author in the Transactions of the Epidemiological 
Society, vol. iv., p. 197, for the years 1875-81. 



PRIMARY AND SECONDARY VACCINATION 51 

of the vesicle we prevent further auto-inoculation, and so 
all further diseased action ceases until we inoculate another 
portion of the skin. The vesicle will then proceed with its 
growth, not, indeed, from the beginning, but from the time 
it had been arrested, and so finish its growth. 

Before going on with the immediate subject-matter of 
this chapter, we will consider another very remarkable fact, 
for it has its bearing upon what we are now considering. 
It is this : if we use lymph which has become inert by having 
been kept too long to produce a vaccine vesicle, yet we 
do produce a certain effect upon the individual we vaccinate 
with such lymph. This influence we can see if we again 
vaccinate successfully the individual, for the subsequent 
vaccination always runs a slightly accelerated course. The 
areola is thus very pronounced on the eighth day. Now, 
what reason can be given for this behaviour of the sub- 
sequent vaccination ? This is the one we offer. V accine 
lymph may be considered to be composed of two parts — 
one the living organism, the other the product of the living 
organism which we assume to be the modifying agent. 

When we, therefore, vaccinate an individual with lymph 
that has lost its vitality from age, we only introduce a small 
portion of the product that has been already formed. No 
fresh amount of product can be formed, as the organism 
which produces it is dead, and therefore no vesicle is 
formed, and only a very slight modification of the system 
is produced in the individual so vaccinated — a modification 
which declares itself in the slightly shortened course run 
by subsequent vaccination when a vesicle is produced. 
This consideration will point to a means of so vaccinating 
an individual that he may become after repeated inocula- 
tions with aged lymph insusceptible of further vaccination 
without his ever having had a vaccine vesicle ; indeed, this 
seems to us a possible explanation of the only case of 
insusceptibility we have ever met with in over 61,000 
cases. The child referred to was ten years old ; its mother 
stated that vaccination had failed on previous occasions. 

4—2 



52 THEORY AND PRACTICE OF VACCINATION 



We failed twice running, but did not get the opportunity 
of trying a third time.* 

Let us suppose that a person once efficiently vaccinated 
has proceeded from on our imaginary line to 9 ; that 
there is a tendency to return, and that the retrograde 
journey may be quick or slow. We are acquainted with 
some of the conditions that influence the return journey, 
and we will name those we know at once, viz., the number 
of places a person is primarily vaccinated in. 

In a considerable number of persons only vaccinated in 
one place, their return journey is quicker than if they had 
been vaccinated in four or more. We base our assertion 
upon the following evidence : 

Mr. Marson, formerly the Medical Officer of the Inocula- 
tion and Small-pox Hospital at Highgate, published the 
following table, contained in a paper which he wrote as an 
article on small-pox published in the Medico-Chirurgical 
Society Transactions, vol. xxxvi. 



Cases of small-pox, classified according to the vaccination-marks 
borne by each patient respectively. 


Number of deaths 
per cent, in each 
class respectively. 


1. Stated to have been vaccinated, but having no 




cicatrix... 


21f 


2. Having one vaccine cicatrix 


7£ 


3. Having two vaccine cicatrices ... 




4. Having three vaccine cicatrices ... 


If 


5. Having four or more vaccine cicatrices 




Unvaccinated ... 


351 



In compiling this table, Marson deducted the cases where 
a person not only died of small- pox, but also of some super- 
added disease ; but he gives the number he so deducted, 
so for our purpose we may add these to his figures, and 
recast the percentages. This being done, we obtain the 
following number : 

* Eeport of the Medical Officer of the Local Government Board for 
1887, seventeenth annual report, p. 28. 



PRIMARY AND SECONDARY VACCINATION 53 





Cases. 


Deaths. 


.M ortality 
per cent. 


Unvaccinated 


2,654 


996 


37-2 


Stated to have been vaccinated, but 








having no cicatrix ... 


290 


74 


25-5 


Having one vaccine cicatrix 


1,357 


125 


9-2 


Having two vaccine cicatrices ... 


888 


53 


5-9 


Having three vaccine cicatrices 


274 


10 


36 


Having four or more vaccine cicatrices 


268 


3 


11 



Dr. Gayton, late Medical Superintendent of the Homerton 
Small-pox Hospital, has also published some 10,403 cases 
of small-pox, noting also the number of scars of primary 
vaccination on those who had been vaccinated. Subjoined 
are his figures. It is to be understood that Dr. Gayton, in 
compiling his table, threw out no cases of superadded 
diseases, so that Marson's table, as we have recast it, is 
strictly comparable with Gayton' s : 





Cases. 


Deaths. 


Mortality 
per cent. 


Unvaccinated 


2,169 


948 


43-7 


Stated to have been vaccinated, but 








having no cicatrix ... 


1,295 


352 


27-1 


Having one vaccine cicatrix ... 


1,988 


220 


11-07 


Having two vaccine cicatrices ... 


2,225 


178 


8-04 


Having three vaccine cicatrices 


1,573 


82 


5-22 


; Having four or more vaccine cicatrices 


1,153 


37 


3-2 



In comparing these two tables, we at once notice that all 
the death percentages of Gayton's table are in excess of 
Marson's. For instance, Gayton's death-rate among his 
unvaccinated class is 43*7, while Marson's is 37*2. As far 
as this evidence goes, it shows that small-pox was more 
fatal among the unvaccinated in Gayton's time than it 
was in Marson's ; that being so, it is remarkable that if 
we reduce the other percentages of Gayton by the 
fraction gf we arrive at results which are almost identical, 
and on such an inquiry the discrepancy is well within the 



54 THEORY AND PRACTICE OF VACCINATION 



limits of what may be attributed to ' personal equation,' to 
borrow a phrase used in astronomical science. 

In the next table we give Gayton's percentages so re- 
duced and compared with Marson's : 





Marson's 
Mortality 
percentage. 


Gayton's reduced 
, 37-2 
by 4F r 


Unvaccinated 

Stated to have been vaccinated, but 

having no cicatrix ... 
Having one vaccine cicatrix 

Having two vaccine cicatrices 

Having three vaccine cicatrices 
Having four or more vaccine cicatrices 


37-2 

25*5 
92 
5-9 
36 
1-1 


23 
9-42 
6-9 
4-9 
19 



We say this is a very close result of two different 
observers, and shows by undesigned coincidence how 
accurate both must have been in the collection and regis- 
tration of such a mass of material. 

That so great a difference should be observed in the per- 
centage of mortality among the unvaccinated between the 
collection of Marson's and Gayton's statistics, seems to call 
for some comment. We do not think that there is any 
doubt that the fatality of small-pox has been increasing 
among the unprotected class since the commencement of 
this century, that is, from the commencement of vaccina- 
tion. The death-rate among those having the natural 
disease at this time does not seem to have been greater, at 
most, than 22 per cent. ; for out of 1,200 who took small-pox 
in Norwich in 1807, 203 died, i.e., 16*9 per cent. Also in 
the village of Ware in 1722, 612 persons suffered from the 
small-pox, of which number 72 died ; this gives a per- 
centage of 11 "7.* 

Dr. J. Kirkpatrick,! in 1754, quoting Mr. Wall, of the 
Inoculation Hospital, says that, out of 1,415 small-pox 

* See Dr. Monro's ' Observations on the Different Kinds of Small- 
pox,' vol. i. of the Eoyal Society's MS. Letters and Papers concerning 
Inoculation, p. 21. 

f J. Kirkpatrick, ' The Analysis of Inoculation,' published in 1754, 
p. xxiv in the preface. 



PRIMARY AND SECONDARY VACCINATION 55 

patients at that institution, 421 died, or 27*75 per cent.,, 
and adds, ' This is, indeed, an uncommon proportion,' and 
he gives some reasons to account for it. 

Mr. Cross in the Norwich epidemic (before mentioned) 
found 46 who died out of 200 cases, and 50 who died out 
of 357, together being 17*24 per cent. From these examples 
— and they are not selected ones, but those we have met 
with — in all they amount to 3,784 cases, among whom there 
were 792, or 2090. This we will take as the death per- 
centage at the commencement of this century. The average 
time at which Marson collected his statistics was 1846, and 
he gives 37*2 as the percentage mortality of the disease at 
that time. 

Dr. Gayton, in 1878, being the mean year during which 
he was collecting his cases, found the percentage mortality 
43*7. Further, Dr. McCombie, in a paper entitled ' Com- 
parison of Small-pox Statistic Epidemics, 1871 and 
1876,' compiled from reports furnished by the medical 
superintendents of the various small-pox hospitals of the 
Metropolitan Asylums Board,* gives the mortality of 
the 1871 epidemic as 44*6 per cent., 3,649 cases, and 
1,628 deaths ; for 1876 epidemic as 45*5 per cent., 1,693 
cases, and 771 deaths. Thus, we find the mortality 
at the commencement of the century 22 per cent. ; in 
1846, when Marson collected his statistics, 37*2 per cent. ; 
in 1878, when Gayton collected his statistics, 43*7 ; in 
the epidemic of 1871 the mortality was 44*6 ; and in the 
epidemic of 1876 the mortality was 45*5. We are by this 
led to believe that there has been an increasing death-rate 
among the unprotected portion of the population. If this 
be true, of what value is the argument of those who say 
the diminished fatality of small-pox at the present time is 
due not to vaccination, but to the exhaustion, so to speak, 
of the disease, and that our present immunity from the 
plague, from typhus, and from leprosy, are analogous 

* Transactions of the Epidemiological Society, vol. iv., 1875-81 
p. 188. 



56 THEORY AND PRACTICE OF VACCINATION 



instances ? We have shown a reason for believing small- 
pox, instead of decreasing in fatality, has really doubled in 
virulence among a certain class, viz., the un vaccinated. 

The reason for this increase of small-pox fatality among 
the unvaccinated population is, we believe, the following : 
When a disease has become endemic in a country for some 
centuries, and spreads among the population unchecked, 
we generally find the tendency is for the mortality from 
such a disease to decrease. Especially would this be the 
case with a disease like small-pox, which we have already 
shown to be a disease of childhood in unvaccinated com- 
munities. Almost everybody has the disease at some 
period of life, in the great bulk of people before they are 
twelve years old. Hence most individuals would have had 
their attack of small-pox before marriage, and chiefly those 
who had successfully combated the disease would be propa- 
gators of their race. We will take for granted the fact 
that physical properties are largely inherited, and there- 
fore the children of those parents who had successfully 
combated the disease would be more likely to combat 
successfully with the same disease, i.e., they would inherit 
a power more or less of resisting death from small-pox, 
and in this sense might be called stronger than those who 
would die. The population would, after some years, become 
gradually strengthened against death from small-pox, and 
the mortality of the disease would decrease. 

Any method which would allow all to live and propagate 
their kind, such as vaccination, would remove this means 
of strengthening the population against small-pox, and 
hence those of the population who did not avail them- 
selves of the method of safety would, after some years, 
feel the full brunt of the disease, and thus the fatality 
would gradually increase among them to such a degree 
as we know the mortality to be among a community 
which has never as yet had the disease, or not had it 
for some long time among them. We may instance how 
very fatal syphilis was when it first appeared in Europe, 



PRIMARY AND SECONDARY VACCINATION 



57 



and how fatal measles was among the Fijians in our own 
time (1875). It is true Dr. Corney attributes this mortality 
to the mistreatment of the disease by the natives. On 
page 84 of the Transactions of the Epidemiological Society, 
vol. iii., 1883-84, indeed, he mentions the reason we have 
given for the high mortality, but only to reject it. We 
may, therefore, be allowed to form our own opinion upon 
the matter. 

Another factor which we know influences the return 
journey along our imaginary line is the character of the 
lymph used. As an illustration we will relate the follow- 
ing details : On December 15, 1875, we vaccinated a child, 
E. C, six months old, in four places. On the 22nd the 
child returned with two very small vesicles. The child 
had four more places inoculated on the 22nd, and when it 
returned on the 29th these were found to have all taken. 
Lymph was then taken from it and used for the vaccination 
of eight children in four places each. Of these the vaccina- 
tion failed in four cases, one apparently took in three places, 
and two others in two places, producing small sores, 
with a light yellow scab. The one that was vaccinated in 
three places the mother refused to have done again, but 
the other two were re-vaccinated, one on January 12, 1876, 
and the other on March 8, and both took well in four 
places. This could not have been the case if the lymph 
had been taken at the proper time. From this case we 
may learn that lymph taken fourteen days after the first 
inoculation which is successful, though it be taken on the 
eighth day from the inoculation of the yielding vesicle 
— that such lymph, though capable of producing a local 
lesion on another individual, is, nevertheless, incapable of 
rendering the system immune from further vaccination. 

Some apology to our readers seems called for for describing 
this last experience of ours. It must be remembered that 
the circumstances to which it relates occurred nearly 
seventeen years ago, before we had our present experience, 
and want at the time of knowledge must be our excuse. 



58 THEORY AND PRACTICE OF VACCINATION 



In Nature of March 22, 1888, there is a short review of 
Dr. C. Creighton's book, ' Cow-pox and Vaccinal Syphilis,' 
and there we offer what we consider a very striking analogy 
which exists between vaccination and syphilis. We assume, 
however, a controversial matter, that of the original identity 
of the virus of the two kinds of venereal sores. For we 
believe that the virus producing the hard infecting sore is 
that inoculated at the time of its potency, whereas the 
virus which produces the local lesion only, or soft sore, is 
that inoculated at a time when the virus is old. In think- 
ing rationally of this analogy, we might bear in mind the 
respective incubatory periods of the two diseases, syphilis 
and vaccinia, the latter being so much longer than the former, 
and consequently the much greater opportunities in the 
latter of getting a degenerate virus. 

There is also another cause that influences the return 
march, which we can describe less definitely than the other 
two causes ; but nevertheless it is quite as efficient, or even 
more so, to hurry or delay the return march. We will 
name this ' individual peculiarity.' As an example of what 
we mean, we will instance the liability of certain individuals 
to take small-pox twice in their lives. This, however, is very 
well known to be the exception of the ordinary experience, 
and we can at present only attribute this liability to some 
individual peculiarity, but of this we will speak more fully 
when on the subject of re-vaccination. There may be other 
causes which influence the return march which we know 
little or nothing about, but the three we have given will 
suffice for our purpose of illustration. 

We will now suppose a person once vaccinated and to 
have arrived at the desirable point 9 of our imaginary line, 
and let us assume that every individual once vaccinated has 
a tendency to return to his original condition, represented by 
on this line. We will further suppose that his return march 
is gradual, and that he has returned as far as the position 
marked 4 on the line. If such an individual were now 
re-vaccinated he would take up the disease at 4, and then 



PRIMARY AND SECONDARY VACCINATION 59 



again complete his journey at 9. The re- vaccination would 
only run a five days' course. On this theory, the more 
rapid course a re- vaccination ran in an individual, the longer 
time that individual would have before he could contract 
small-pox. There are reasons for thinking that an individual 
would not be liable to contract natural small-pox until he 
had returned as far as the position marked 4. That is to 
say, if his re-vaccination took five days before the vesicles 
were at their height, then we may regard such an individual 
to have just arrived at the point in his return march at 
which he would take small-pox if exposed to it ; that if he 
was between three and four he would have but a modified 
attack, and if beyond three on his return journey, then he 
would have small-pox as badly as if he had never been 
vaccinated. 

What reasons have we for asserting this dogma ? Marson, 
in his article on small-pox, published in vol. i., p. 477, of 
Keynolds' ' System of Medicine/ lays down the following 
law after the observation of many cases. He says the 
incubatory period of small-pox is twelve days, and that if 
a person be vaccinated during the first three days of the 
incubatory period of small-pox, such a person would escape 
the later disease entirely ; but if a person's vaccination was 
delayed till between the third and fourth days of the incu- 
batory period of small-pox, then he would have a modified 
attack of the disease, and if the vaccination was still further 
delayed beyond the fourth day of the incubatory period, 
then such an individual would have small-pox and vaccinia 
together, the one disease being uninfluenced by the other. 
We have seen several cases which have entirely corroborated 
Marson's law, so that we have every reason to believe it 
true. We will relate three cases, for they will illustrate 
not only our direct object, but also indirectly one of two 
others we wish to insist on. 

Case I. — The following case is partially given on page 10, 
but it is now more fully related : 

A woman's husband was taken ill with small-pox on 



6o THEORY AND PRACTICE OF VACCINATION 



Wednesday, December 20, 1871. She had three un vac- 
cinated children, two girls and a boy. These she took to 
Surrey Chapel on the following Tuesday, December 26, 
to be vaccinated. They were apparently vaccinated by 
Mr. Marson in six places, three being placed on each arm, 
in a position with regard to each other which was habitual 
with Mr. Marson. The names and ages of the children 
were : Herbert, aged six ; Clara, aged four ; and Laura, 
aged three months — the last having been born on Sep- 
tember 24, 1871. The two girls became ill with small-pox 
on Sunday, December 31, i.e., on the twelfth day after their 
father, and they were vaccinated on the seventh day of the 
incubatory period of small-pox. Clara died on January 8, 
1872, of the disease, although her vaccination had taken as 
well as Laura's. Herbert escaped altogether. Laura we 
saw on January 16, 1895, at St. Thomas's Hospital. She 
was then severely scarred with small-pox, and had lost an 
eye from the disease. She, however, bore six good foveated 
scars of vaccination, such as we have seldom seen produced 
on a person who has previously suffered from small-pox. 
She affirmed that she was vaccinated before she had small- 
pox, but knew nothing further of her vaccination. She, 
however, gave me her mother's address, and, upon calling, 
her mother related the above particulars, except for the 
exact dates. These, however, we are able to supply from 
the register of the time, which was found to tally, as far as 
it went, precisely with the mother's story. 

Case II. — A policeman brought three of his children 
to be vaccinated at Victoria Hall. They were aged re- 
spectively 11, 9, and 7 years. The eldest was a boy, the 
two others girls. These three children were vaccinated on 
May 26, 1881. Two of the children had been sleeping in 
the same room with their elder brother, and his eruption 
of small-pox first appeared on May 18. 

Having paid some attention to the infective power of 
small-pox during its incubatory stage, we have come to the 
conclusion that small-pox is not infective to other persons 



PRIMARY AND SECONDARY VACCINATION 61 



until this stage is over. The chances of two unvaccinated 
children sleeping in the same room as one with small-pox 
are greatly that they contract small-pox at the earliest date 
possible, and that will be, according to our experience, twelve 
days after the appearance of the disease in the first attacked. 
We should therefore look on May 30 as the day on which the 
eruption should appear in the two unvaccinated children, 
and this day really was the first day on which the two 
children manifested the disease. In the other, where the 
probability of infection was not so great — i.e., in the child 
who was not sleeping in the same room, but who had access 
to her brother's — the child fell with the small-pox two 
days later. Thus we see in this man's family, consisting 
of himself and five children, only the man himself and his 
youngest child — both of whom had been vaccinated some 
time previous to exposure — escaped, while all the rest had 
small-pox. Three of these latter were vaccinated on the 
ninth day of the possible exposure, and these all had small- 
pox as badly as they could have it. The other, who was 
the eldest lad, and who had never been attempted to be 
vaccinated, also had the disease severely. We may add 
that we visited the cases, which were admitted to the Stock- 
well Small-pox Hospital, and they all presented the appear- 
ance of the unmodified form of the disease. The vaccination 
had taken in all three in every place, and the small-pox 
eruption was even more abundantly distributed within the 
area of that occupied by the vaccine vesicles, and for a short 
distance around. These cases, therefore, we may reason- 
ably suppose were vaccinated on the ninth day of the 
incubatory period of small-pox, which was not modified 
thereby. We saw both the individuals who were vaccinated 
on May 26, 1881, one on June 15, 1895 ; the other on 
July 10, 1895. Both of them were pitted, and both had 
five indistinct scars of vaccination. Another case which we 
think worth recording, because the dates we can also 
accurately give ; but the subject of this record had been 
previously vaccinated in infancy, and therefore the deduc- 



62 THEORY AND PRACTICE OF VACCINATION 

tions to be drawn are not of so much value as in the former 
example. 

Caselll. — A gentleman, aged twenty-three years — a house- 
surgeon at St. Thomas's Hospital — in the beginning of the 
year 1871, which will be remembered as the greatest 
epidemic year of small-pox since the introduction of vaccina- 
tion, saw and attended to a man who had been admitted 
with a fractured leg, and afterwards developed small-pox. 
The date on which he contracted small-pox was probably 
January 30, 1871. On February 1 he was vaccinated on 
the right arm, and on Wednesday, the 8th, he was taken ill 
with what proved to be small-pox, and admitted to the 
small-pox ward on the 9th. He had an abundant eruption, 
but this was not present on the right arm, or for an area 
round the vaccine vesicles. Here vaccination was presum- 
ably done between the third and fourth days of the incubatory 
period. The attack was a mild one, and this gentleman's 
face is not pitted or disfigured in any way. It is true that 
his previous vaccination in infancy must have had much to 
do with the modification of the disease, but the fact of there 
being no small-pox eruption on the right arm, and for a 
certain area round the vaccine vesicles, showed that the 
then present vaccination had some modifying effect, 
especially when we remember that in the first case reported 
the small-pox eruption was more abundant between the 
vaccine vesicles, and for some short distance in the area 
around them. From the observation of such cases as the 
three above related, Marson deduced his theory, and as 
the three cases which we have met with are entirely in 
accord with Marson's experience, we accept it. 



LECTURE IV. 



THE ERUPTIONS THAT OCCASIONALLY FOLLOW VACCINATION. 



When we first began vaccinating we made it a rule to inquire 
into the history of all children who had eruptions following 
vaccination, especially those on whom the rash presented 
any appearance of syphilis. We know very well what the 
ordinary course of acquired syphilis is. Briefly to recall 
the chief points important for our present purpose, they 
are : first, a period of incubation of about three to five 
weeks, and this rule holds on whatever part of the skin the 
individual may inoculate him or herself ; second, there is 
another interval of time between the development of the 
chancre and the appearance of the rash. This second interval 
is usually about two to four weeks more ; so that it would 
be five to nine weeks from the inoculation of syphilis until 
we saw the secondary rash upon the body. The ordinary 
course of hereditary syphilis is for the appearance of the 
rash to follow after the same interval that occurs in the 
acquired disease between the development of the chancre 
and the appearance of the secondary rash, the interval 
between the inoculation and the development of the chancre 
being annihilated. Now, eruptions which follow vaccination, 
even if of a syphilitic nature, nearly always appear about 
the tenth day after vaccination, and it follows, that if this 
appearance of a syphilitic rash on the tenth day is due to 
the inoculation of syphilis at the time of vaccination, the 
disease in such cases persistently follows a very unusual 



64 THEORY AND PRACTICE OF VACCINATION 



course. This unusual course is not to be noticed in the 
twenty-six cases or so which Mr. Hutchinson* has published 
of syphilitic inoculation after vaccination, and in one case 
which we saw the disease followed its usual course unmodi- 
fied by vaccination. For instance, it took twenty-one days 
from the vaccination to the first appearance of the chancre, 
and thirty-six days from the first appearance of the chancre 
to the appearance of the secondary rash — fifty-seven days in 
all, or one day more than eight weeks. Hence we may fairly 
assume that when syphilis is inoculated at the time of 
vaccination it will follow its usual course. The explanation 
why the eruption appears so frequently on the tenth day of 
vaccination is, we think, because the child so affected is suffer- 
ing already from hereditary syphilis, and the skin irritation 
occasioned by the vaccination simply determines the time 
of the appearance of the rash. Vaccination, there is no 
doubt, is a cutaneous irritant, much less so, however, than 
small-pox. With the former it is only the weak skins, or 
those suffering from some idiosyncrasy, that suffer. In the 
latter the irritation is so strong that all skins break down, 
and that in a definite manner, and the rash is therefore 
characteristic of the disease. 

The rashes which follow vaccination, however, are not 
definite— in fact, are as numerous in character as there are 
rashes to which children are liable ; they are determined 
more by the nature of the child's organism in whom they 
occur than by the vaccinia. It is thus we explain the 
very various forms of eruption which are met with after 
vaccination : it may be a general erythema, or an eczema, 
or an urticuria, or a lichen, or may partake of the appearance 
of any other rash to which children are liable. Measles, 
scarlet fever, and small-pox have each of them their own 
special character of rash, so that, from seeing them, it is 
possible to say to which of these diseases they are to be 
referred. With vaccinia this is impossible, the appearance 
of the rash, if it exist at all, being so indefinite. It is well 
* ' Illustrations of Clinical Surgery,' 1875. 



I 



PLATE V 




ERUPTIONS THAT FOLLOW VACCINATION 



65 



known that certain local irritations are sufficient to cause 
lesions in weak skins. Thus, the wet napkin will cause 
intertrigo ; a common head cold will cause sores about the 
orifice of the nose ; the saliva will cause the angles of the 
mouth to be cracked, sore, and tender ; and the perspiration 
from the head will cause impetiginous sores behind the ear, 
etc. On skins on which these local conditions are sufficiently 
potential to cause mischief, vaccination will also be potential 
to do the same, and the vaccine vesicle will be ill-developed 
or abnormal in appearance, and cannot be expected to confer 
the most lasting immunity from small-pox that vaccination 
is capable of affording. For a common appearance of the 
vaccine vesicle under the above abnormal conditions see 
Plate IX., Lecture V., p. 70. Fig. 1, Plate V., was taken 
from a child whose father contracted syphilis shortly before 
his marriage. It was the second child of the marriage ; the 
first died within a very short period of birth. This child, 
being apparently healthy, was vaccinated at St. Thomas's 
Hospital in 1878. It was duly inspected, and was brought 
again with the eruption represented, which first appeared 
on the tenth day after vaccination. This is a very good 
example of the cases of alleged syphilis after vaccination. 
It is so tempting for parents to lay the results of their own 
iniquities upon vaccination, especially when they are en- 
couraged so to do by shameless agitators. To enable us to 
view the truth of these allegations against vaccination, we 
will suppose a man to have had syphilis and to play a 
game of football : he receives a kick on the shin, and in 
due course a syphilitic node may develop from the bruise. 
The man would be as entitled to say he acquired his syphilis 
from playing football as a parent of a child who has had 
syphilis would be to say that the child acquired its syphilis 
from vaccination. 

There is one more most striking fact which receives an 
easy explanation from the above view, and would be other- 
wise quite incomprehensible without it. We allude to 
syphilitic eruptions following the use of calf lymph, and 

5 



66 THEORY AND PRACTICE OF VACCINATION 



that about in the same proportion as after the use of 
human lymph. It may be accepted without doubt that 
calf lymph which has never passed through the human 
being since its origin is perfectly free from the syphilitic 
taint, and yet syphilitic eruptions follow its use. This fact 
alone should, in this particular of syphilitic infection, 
restore our confidence in the use of human lymph. 

Another eruption to which children are subject after 
vaccination is urticaria. It is well known that adults who 
are liable to urticaria may have it readily excited by slight 
causes. Thus, a scratch is often sufficient, or a meal of 
shell-fish, especially crabs or mussels. Oatmeal will pro- 
voke it in others ; strawberries in others, etc. Plate V., 
Fig. 2, represents a severe form of the eruption as it 
occurred in a child, A. K. T., in 1879. Plate VI., Fig. 1, 
also represents the right flank of the same child, and 
Plate VI., Fig. 2, represents some of the spots about the 
natural size, with the details filled in. The child was 
vaccinated on November 4, at Surrey Chapel, from human 
lymph. The rash first appeared on November 13 ; the 
drawing was taken on November 19. On the sides of the 
cheeks, on the dorsum of the feet and the backs of the 
hands, the eruption became vesicular or even bulbous ; but 
not so on other parts of the body. This severe form of the 
rash follows vaccination in about 1 in 10,000 cases. It is as 
common after calf lymph as after human lymph, and the 
inoculation of another child with the serum from the 
vesicles produces no result, having first ascertained its 
harmlessness by self -inoculation. The eruption again 
appeared two or three months later during dentition. 
Plate VII. represents an urticaria, the drawing being taken 
at a late stage of the eruption. 

Another eruption which happens after vaccination is 
eczema, chiefly occurring about the head and face, or as 
intertrigo about the buttocks, axilla, or in the folds of the 
neck. Impetigo behind the ears is also met with, and 
tinea tarsi ; but these evils are often excited by local 




"West, Ifevvaoaa-ri chromo 



PLAT E VII 




West. Newman cTafomo. 



P L ATE VIII. 





West, Newman cKromo 



ERUPTIONS THAT FOLLOW VACCINATION 



67 



irritations, as we have already said, before vaccination, 
and only when they occur after vaccination can vaccination 
be truthfully accused of being an exciting cause. 

Lichen in its various forms may also follow vaccination, 
but lichen also occurs during dentition in some children. 
See Plate VIII., which illustrates this in a severe form ; 
this rash came out on the tenth day after vaccination from 
calf lymph.* When lichen occurs during dentition, this, 
we think, must be caused by some abnormal process of 
digestion ; the irritation of the mouth reaches the stomach, 
thus giving rise to the abnormal process. The abnormal 
products are absorbed, and these, circulating in the blood, 
irritate the skin and occasion the eruption which at such 
time often appears. Mothers, as a rule, are quite aware 
that their infants may suffer from eruptions of various kinds 
during dentition, and they are content when they say that 
the child has a gum rash. They then rightly never think 
of attributing it to the impurity of the tooth that the child 
has just cut, but if the eruption happens to follow vaccina- 
tion the hated rite gets the blame. 

We have once seen purpura follow vaccination in the 
same way as purpura may be an early symptom of small- 
pox. Haemorrhage into the vesicles we have also seen 
in one child who was suffering from whooping-cough. 
Haemorrhage in this case was no doubt due to the conges- 
tion of the skin caused during the paroxysms of the cough. 

Mr. Hutchinson, on December 9, 1879 (British Medical 
Journal, p. 960, December 13, 1879), exhibited the body of 
a child (at the Medico- Chirurgical Society) which had been 
vaccinated on November 11. An eruption had come out 
by the eighth day, which the medical man under whose 
care it was believed to be variola. Three days later the 
vesicles of the eruption were surrounded by large red 
areolae, which became circular gangrenous patches. The 
skin where the eruption had been was, at the time the 

* The artist has not been happy in the representation of the body 
form, but the eruption is faithfully represented. 

5—2 



68 THEORY AND PRACTICE OF VACCINATION 



body was exhibited, as if it had had a hole punched out, 
so abrupt were the margins of the wounds. Another case 
of this complication after vaccination is published in the 
Dublin Journal of Medical Science for June, 1880, by 
Mr. William Stokes. 

The child in question was vaccinated on February 7, 
1880. On the morning of the 9th a number of purple and 
black spots appeared first on the buttocks, next on the 
face, and subsequently all over the body. The sloughs 
appeared, as in Mr. Hutchinson's case, over the sites of 
the eruption. There were three well - marked vaccine 
vesicles on the arm, which appeared healthy. 

In Guy's Hospital museum there are two wax models of 
what is called varicella gangrenosa. These exactly resemble 
the gangrenous patches in Mr. Hutchinson's case, and we 
think the same conditions of system were present in all 
those children who so suffered — two after vaccination and 
two after chicken-pox — and we are inclined to believe that 
disseminated tubercle was the real cause of them. 

Auto-vaccination is occasionally seen. We have seen it 
in children who had intertrigo in the groin, and who, after 
scratching their vaccinated arms, had transferred their 
hand to their groins, thus producing a crop of vesicles on 
this part. We have also seen vaccine vesicles on the face 
from the same cause, and we have twice seen a general 
eruption of vaccine vesicles on the body in children who 
had been vaccinated. In both these cases the children were 
in public institutions, and had been thoroughly washed 
every morning by a nurse of the institution. As tow is 
very properly used in general instead of a sponge, and the 
vaccinated arm had taken part in the ablution, the tow, 
having been wiped over the rest of the skin, had caused a 
general inoculation of the surface. This seems to be more 
frequent in France than in England, and the French have 
given it the name of vaccina generalisee ; but that it is due 
to wholesale auto-vaccination we have little doubt. 



LECTUEE V. 



THE PRACTICAL DETAILS OF VACCINATION. 

We shall first speak of the lymph which it is best to use, 
and how it should be used. 

It is always best to use perfectly fresh lymph, and to 
vaccinate directly from arm to arm or from calf to arm.* 
The lymph used from child to child should be taken not 
later than the eighth day, i.e., on the day week. The child 
which is to be the vaccinifer is vaccinated, say, on Tuesday, 
and the following Tuesday the lymph should be taken. 
The lymph should not be taken later than on this day, for 
if it be, it has a great tendency to produce unduly inflamed 
arms on the children vaccinated, or to produce abortive 
vesicles, called by the first vaccinators spurious vesicles. 
These vesicles may not be protective against further 
vaccination, and certainly do not give that lasting pro- 
tection against small-pox that properly performed vaccina- 
tion is capable of giving. The lymph may be taken earlier 
without the chance of these untoward results, but it is 
difficult to obtain any quantity on the earlier days. 
Further, the lymph taken after the day week is seldom 
effective after a week's storing. 

Lymph from a re-vaccination should in no case be used ; 
nor should lymph from a much -inflamed arm, or lymph 
that is thin or serous. Thick lymph, which at first oozes 

* In saying this, gentlemen, I should tell you, however, that, 
although such has been the policy of the Local Government Board up 
to the present time, there is the probability that this policy before long 
will be altered, when different instructions will have to be given. 



7o THEORY AND PRACTICE OF VACCINATION 



from the vesicle when it is pricked, should be used. No 
child that is unhealthy or has any skin eruption should 
be used as a vaccinifer, and in all cases care should be 
taken to examine the buttocks of any child from whose 
arm the lymph is taken to vaccinate another. This last 
precaution is very necessary, for we are able to eliminate 
all cases of dangerous children. Syphilitic children during 
the latent or incubatory period of the disease are not in- 
fective, but become so immediately the symptoms declare 
themselves. It has been thought that if the lymph was 
used unmixed with blood then there was no chance of con- 
veying syphilis ; but this is an error. The proper pre- 
caution to take is to note if there be any symptoms of the 
disease present in the vaccinifer, and to reject all suspicious 
children. The lymph from an apparently healthy child is 
perfectly safe, although it may be incubating the disease. 
Eczema in children is a skin disease which frequently 
causes the vesicles to be ill-formed and sloughy - looking, 
of which Plate IX. represents a case. Of course lyrnph 
should never be taken from an abnormal vesicle to vaccinate 
others. Lymph which is carelessly selected has a great 
tendency to become weak, i.e., it produces persistently what 
are called advanced arms, that is, an arm where the areola 
is formed on the seventh day instead of the eighth, and is 
consequently very well marked on the eighth day, when it 
should only be forming. Some practitioners consider the 
eighth too early for the areola to be present, but we are 
sure this is a mistake. We always like to see a little areola 
on the eighth day. If there is none, the child is often out 
of health, or has possibly been taking mercury in some 
form, usually as gray powder. We have noticed this to be 
the case over and over again, viz., that mercury has the 
power of delaying the appearance of the areola. We have 
also given mercury in healthy infants for a week before 
vaccination, and continued the drug during vaccination, with 
the same result. Plate X. shows a typically good arm, from 
which lymph might be taken. 



West, Newman chfomo 



PLATE X 




West, Newman chrome 



PLATE XI 




West,Newman cTnr-om.0 



THE PRACTICAL DETAILS OF VACCINATION 71 



The vesicles should be pricked towards the margins with 
an ordinary sharp bleeding lancet, the flat of the instrument 
being held parallel to the surface of the skin (Plate XL). 
In this way blood is usually avoided. It would be otherwise 
if the lancet were held perpendicularly. The vesicle should 
be pricked all round the margin, for, as we have before 
stated, the lymph is contained in a sort of honeycombed 
structure, and therefore requires a good many punctures 
for its liberation (Plate II., p. 43). 

If the vesicles be shallow, they are very difficult to prick 
without drawing blood, and if this should happen, care 
must be taken not to mix the blood with the lymph, for if 
this be done the lymph should not be used. It is best to 
wait a minute or two before we endeavour to take lymph 
either on the lancet or in tubes or points, and having 
waited, it will be found that the blood has coagulated, and 
may then be removed on the point of the lancet without 
mixing with the rest of the lymph. 

The next step is to attend to the child that has to be 
vaccinated. The left arm is the one usually selected, and 
it is the one most convenient for the vaccinator. The arm 
should be taken out of the sleeve, and held in the left hand 
of the vaccinator, between his fingers and thumb. This 
gives him a firm hold of the child's arm, and he is not so 
likely to be interrupted by a hysterical mother during the 
performance of the act. It also enables him to blanch the 
skin of the arm where he is about to vaccinate by drawing it 
tight between his fingers and thumb, and thus preventing 
bleeding taking place during the act ; and, lastly, it drags 
the incisions apart, and allows the lymph to touch the 
fresh-cut surface. The lancet should be blunt, and the 
incision made obliquely. The blunt lancet is preferred 
because it tears rather than cuts the capillaries, and a torn 
vesicle, as every surgeon knows, bleeds less than a cut one. 
The incision is made obliquely, because the portion of the 
skin that the first changes occur in, as has before been 
stated, is the middle layer of the rete Malpighii, and an 



72 THEORY AND PRACTICE OF VACCINATION 



oblique incision exposes a larger area of this than a per- 
pendicular one. An oblique incision also causes less 
bleeding than a perpendicular one. The lancet used for 
vaccination should never be used for any other purpose. 
It should be dipped in water after each vaccination, and 
wiped upon a clean towel. It is also a good plan to heat 
it in a spirit-lamp before commencing the day's vaccination 
and chilling it in water. This method does not improve 
the appearance of the lancet, but it is a very effective 
means of disinfecting the instrument. The lymph is taken 
from the vaccinifer on one side of the lancet, and should 
cover its tip ; the side of the instrument which is free from 
lymph should be the side next the skin while cutting ; the 
blade of the lancet should be turned on the handle, so that 
it is at right angles with it, and the upper part of the 
blade is to be held between the thumb and middle ringer, 
with the forefinger on the angle made by the blade and 
handle. The little and ring-fingers should rest on the arm 
to be vaccinated, and the cuts made upwards, and the 
lymph placed on the cuts and gently pressed in with the 
flat of the instrument. "When well-selected lymph is used, 
and after very little practice, it will be found that at least 
94 per cent, of the insertions of the lymph are successful. 
Our own insertion success with humanized lymph, directly 
from arm to arm, for the last twenty-two years at St. 
Thomas's Hospital and Surrey Chapel was 96*18 per cent., 
there being 9,011 cases. 

It will be convenient here to refer to the so-called in- 
susceptibility of individuals to vaccination, and we cannot 
do better than quote a note of the late Medical Officer of the 
Local Government Board, Sir George Buchanan. It is as 
follows : 

' The following passage (from Medical Officer's 1887 Beport) 
contains the experience of Dr. Cory, as to what is called 
' insusceptibility ' of children to vaccination : 

1 " In accordance with your wish that I should record my 
experience of vaccinating children who have been certified 



THE PRACTICAL DETAILS OF VACCINATION 



73 



as 1 insusceptible,' I have to inform you that at various 
times four such cases have been sent to me at Surrey 
Chapel, and five to Lamb's Conduit Street, and that in 
every such case my first attempt at vaccination has suc- 
ceeded. The resulting vesicles (whether done with human 
or with calf lymph) have been quite characteristic of vaccine, 
but eight of them were accelerated in their course in the 
same way that I have observed after a first unsuccessful 
operation by myself. 

' " Of my own vaccinations, I may say that I have in my 
time performed over 38,000 primary operations with human 
or with calf lymph, and that it has only once fallen to my lot 
to fail twice at an attempt at vaccination. The subject in 
this instance was a ten-year-old child, in whom, as stated 
by its mother, vaccination had been attempted on previous 
occasions without result. My operation failed at the second 
attempt, and I did not get the opportunity of trying a third 
time. 

4 "I believe the late Dr. Marson has recorded an identical 
experience from several thousands of operations performed 
at Blackfriars Station, where humanized lymph only was 
used."* 

' Dr. Cory has since furnished the Medical Department 
with further details as to his failures, complete and partial. 
They are all based upon experience of primary vaccinations 
with unstored lymph, each operation being performed by 
five superficial scratches. 

' Among some 16,000 first attempts at vaccination with 
humanized lymph, he has had fourteen failures, being at the 
rate of one failure in 1,140 children operated on. 

' Of 22,041 first attempts at vaccination with calf lymph, 
he sets aside 44 cases vaccinated (successfully) for the cure 
of naevi, and 216 others that did not return for inspection. 

* ' I may properly point out that Dr. Cory does not here claim for 
himself any exceptional skill above his fellows. Reporting on his 
insertion success at the Animal Vaccine Station, again he tells of one 
of his colleagues getting results like his own, but a trifle better, during 
consecutive years.' 



74 THEORY AND PRACTICE OF VACCINATION 



Among the 21,781 vaccinated on their arms with calf 
lymph, he has experienced 70 failures at a first attempt, 
being at the rate of one failure in 311 children operated on. 

' The vaccinations of this latter class — those from the 
calf — were therefore distinctly more difficult than those 
done from arm to arm. It is to this more difficult class 
that the following figures relate : 

Five insertions succeeded in 19,925 instances. 

Four „ „ 1,011 

Three „ „ 407 

Two „ „ 224 

One „ „ 144 

All insertions failed in 70 ,, 

' It would appear from the above and other similar con- 
siderations that total failure in primary vaccination is 
explicable without recourse to any hypothesis but that 
which suffices to explain partial failure ; and this cannot, 
by the nature of the case, be an "insusceptibility " in the 
true sense of the word. 

' Nevertheless, there is a so-called " insusceptibility," with 
which, for practical purposes, vaccinators are concerned, 
namely, failure to obtain any vaccine vesicle in a given 
child after three several attempts at vaccination. This 
failure constitutes a statutory " insusceptibility," and it is 
desired to estimate in the present note how frequently 
a "certificate of insusceptibility," in this sense, is to be 
expected from one and another class of operator. 

' It has to be premised that a second attempt at vaccina- 
tion of the same child is not quite so likely to succeed as a 
first attempt, and a third attempt is not quite so likely to 
succeed as a second. If it were not for this consideration, 
the probability of failure after three attempts would be once 
out of x s cases, where x = the number of cases yielding one 
failure at a first attempt. But with allowance for the 
differing probability of success at repeated attempts to 
vaccinate, we must expect a failure at a third attempt 
to occur more often than once out of x* cases. If we can 



THE PRACTICAL DETAILS OF VACCINATION 75 



learn how much more often, we shall be able to foretell the 
probability of failure at a third attempt in the practice of 
any vaccinator for whom the quantity x is known. 

' There are certain American experiences* which go to 
show the probability of failure at a third attempt to be 
once out of two-ninths of x s ; and there are some German 
experiences*)" which would place it at once out of one-ninth 
of X s . There are no English experiences available for such 
an estimate. 

' Let us first use the assumption, derived from American 
experiences, that the probability of failure at a third attempt 
is once out of two-ninths of x s . 

- Now, on the scale of success attained by Dr. Cory when 
vaccinating with calf lymph, x = 311, and 2# 3 -f-9 = 6,684,495, 
and this would be the number of children who would be 
expected to furnish one child " insusceptible " in the 
statutory sense of the word. With humanized lymph, in 
Dr. Cory's practice, the number # = 1,140, and 2.x ,3 -^-9 = 
329,232,000, this being the number of children who would 
be expected to furnish one child " insusceptible " in a 
statutory sense. 

' Or, on a lesser scale of success (one that a practitioner, 
when vaccinating from arm to arm, may reasonably look to 
attain) — say not more than one failure per 100 children 
submitted to operation, we should have # = 100, or 2.r 3 -i-9 
= 222,222, as the number of children who would be ex- 
pected to furnish one " insusceptible " child among them. 

' Or, if a vaccinator's scale of success were so unsatis- 
factory that out of 20 attempted vaccinations he habitually 
experienced one failure at the first attempt, it would be 
expected that a "certificate of insusceptibility" might be 
given as often as once for every 1,778 children presented to 
him for vaccination ; but such a 5 per cent, of first failure 

* Fifth and Sixth Eeports of the Board of Health for New York, 
p. 120. 

f Uebersicht der Ergebnisse des Impfgeschaftes im Deutschen 
Keiche fur 1882, pp. 8, 9, 16, 17, 24, 25, in the Eeport of the German 
Vaccination Commission of 1884. 



76 THEORY AND PRACTICE OF VACCINATION 



is only to be witnessed in the practice of those who vaccinate 
unskilfully, or to an undue extent with preserved lymph. 
A scale of failure amounting to once in every ten first 
attempts cannot but be regarded as inexcusable ; on that 
scale, the frequency of certificates of "insusceptibility" 
would be once in 222 cases submitted to vaccination. 

' From the above calculations, based on the assumption 
derived from American experience, let us pass to examine 
the question on the basis of the German experience, accord- 
ing to which the probability of failure at a third attempt is 
once out of one-ninth of a?; and this would be the number 
to give one instance of what is here called " statutory 
insusceptibility." 

' Then, on Dr. Cory's scale of success, he would not have 
more than one "insusceptible" out of every 3,342,247 
children whom he vaccinated with calf lymph, or more than 
one out of every 164,616,000 children whom he vaccinated 
with human lymph. On the next scale of success, a practi- 
tioner, having at his first attempt one per cent, of failure, 
might expect one " insusceptible " case out of 111,111 
primary vaccinations. And on the unsatisfactory scale 
above considered, where there were no less than five per 
cent, of failures at the first attempt, a vaccinator would be 
expected to certify one case as "insusceptible" out of 889 
children submitted to him ; while on the extravagant scale 
of one failure out of every ten first attempts the statutory 
" certificate of insusceptibility " would be given once out of 
111 operations.' 

Lymph is preserved in two ways at the present time in 
England. Firstly, in capillary glass tubes, and secondly, 
on ivory points. We will consider first how the lymph is 
introduced into the glass tubes. The vaccine vesicles are 
pricked in about twenty places towards their margins, and 
after waiting a minute or two the lymph oozes out and 
collects in small drops on the vesicle. One end of the tube 
is applied to the drop, and it enters by capillary attraction. 
If the tube be held perpendicularly the force of capillary 
attraction will only cause it to enter about one inch in a 



THE PRACTICAL DETAILS OF VACCINATION 77 



tube of average bore, but if the tube be held downwards so 
as to allow the force of gravity to act advantageously, the 
tube may be filled. Two-thirds of the tube, however, 
should only be filled, and when this amount has entered, 
but not before, it should be shaken down in the same way 
as an index of a thermometer, by striking the hand in 
which the tube is held against the other. If the lymph 
is shaken down before all has entered, the column of 
lymph will be broken up by intervening air. Having got 
the lymph in the tube and shaken it down, you next pro- 
ceed to seal the ends ; this is best done by the aid of a 
spirit lamp. The tube is held by the finger and thumb as 
far towards the end as there is any lymph, so that the 
lymph in the tube is prevented from being heated. First 
seal the wet end — that is, the end by which the lymph 
entered ; keep the glass tube red-hot at the immediate end 
without melting it, so that the tube is not closed until the 
carbon which results from the charring of the lymph has 
been burned off the immediate end. If the glass be melted 
before this has taken place the sides of the tube approach 
without coalescing, coalescence being prevented by the 
layer of charcoal, and it is then quite impossible to burn 
the charcoal off because the air cannot gain access to it. 
Having closed the wetted end of the tube, proceed to close 
the other, and to do this turn the other end of the tube 
towards the flame, at the same time slipping your fingers 
and thumb towards the end to be sealed, so as to protect 
the lymph from the flame as you did the first end. Then 
quickly pass the empty portion of the tube through the 
flame, and seal immediately. This you will have no 
difficulty in doing, for there will be no charring of the 
lymph, this being the dry end. It will now be evident 
why the wet end is sealed first, for if we drew this wet end 
through the flame the whole length of the empty part of 
this end would be blackened. 

It will be a useful preliminary practice to try a few 
experiments with tubes. Thus, first take a tube and seal 
one end, then dip it in the ink-bottle — only a very small 



78 



THEORY AND PRACTICE OF VACCINATION 



quantity of ink can enter, for if the ink entered, the air 
inside the tube would be compressed. Now, as capillary 
attraction is a force by which, if the other end of the tube 
was open, the ink would enter, and as the compressed air 
would be a force in the opposite direction to force the ink 
out, the ink would arrive at a state of rest as soon as the 
two forces in opposite directions balanced one another ; 
but as the force of capillary attraction is a weak one, it is 
only able to compress the air in the tube to a very small 
extent, therefore the ink only enters for a very short dis- 
tance. Now pass the tube through the flame of a spirit 
lamp, and rapidly dip the open end again into the ink. As 
the tube cools the ink will rise, for by drawing the tube 
through the flame you have expanded the air, and you can 
see how much air has been expelled by noticing how far 
the ink has entered. If you are quick, you will find that 
about half of the air in the tube has been expelled. 

Now take another tube, seal one end and allow it to cool, 
then seal the other end without drawing any portion of the 
tube through the flame ; the probability will be that a little 
glass bubble is produced at the end of the tube. These 
two little experiments will show you the rationale of the 
processes just advised for the sealing of tubes. There is 
one more little manoeuvre that is useful to know. Lymph 
often coagulates in the tubes, and when you have broken 
both ends off you will often find it impossible to blow it 
out of the tube, but this misfortune may always be avoided. 
Notice which end of the tube the lymph has entered, and 
before you have broken off either end, pass this end through 
the flame of a match, being careful not to pass any of the 
column of lymph through, for a comparatively low tempera- 
ture renders the lymph inert. The steam and expansion of 
the air caused by the heat of the flames will force the lymph 
towards the opposite end, and thus loosen the lymph in 
the tube. You can now break off the ends of the tube, and 
the lymph will be easily blown out. 

About ten tubes may be charged from the arm of a child 
vaccinated in five places, and not more. There is often a 



THE PRACTICAL DETAILS OF VACCINATION 79 



temptation to take more lymph from what is called a good 
yielding arm, but the lymph, after filling ten tubes or so, 
although it looks clear in the tubes, is not so active as that 
which at first flows, and will not produce such successful 
results on other children it may be used for. 

Lymph preserved in tubes should always be kept in a 
cool place away from the light. It has been ascertained 
that two years is about the maximum length of time that 
it will keep active. It loses its activity gradually,, so that 
the insertion success becomes less and less as the age of 
the lymph increases. We submit the following table, 
which gives our experience during the period 1889 to 
August, 1893, at St. Thomas's Hospital and Surrey Chapel 
with humanized lymph as used only by ourselves for 
primary vaccination. 

Table I. 

combined success of humanized tube and point lymph 
used at st. thomas's hospital and surrey chapel during 
the period 1889 to june 30, 1893, by ourselves for 
the purposes of primary vaccination only. tubes 89 
cases, points 27 cases. 



Children, Tube Lymph. 



Different periods kept. 


Cases. 


Insertions. 


Successful. 


Per cent. 


Under 10 days 


17 


85 


57 


67*06 


10 days to 20 days 


9 


45 


25 


55-55 


20 „ 50 „ 


9 


45 


29 


64-44 


50 „ 100 „ 


37 


185 


130 


70-27 


100 „ 150 „ 


6 


30 


22 


73-33 


150 „ 365 „ 


11 


55 


20 


36-36 


2 days to 365 days 


89 


445 


283 


65-39 


Children, Point Lymph. 




Under 10 days 


16 


80 


70 


87-5 


10 days to 20 days 


5 


25 


14 


56-0 


20 „ 50 „ 


6 


30 


16 


53-3 


50 „ 100 „ 










2 days to 44 days 


27 


135 


100 


74-4 



8o THEORY AND PRACTICE OF VACCINATION 



With regard to preserving and using lymph on points, 
in pricking the vesicles to take lymph, the same pre- 
cautions are necessary as for tube lymph, saving that, if 
blood be drawn from any vesicle, this should be absolutely 
rejected, for it is impossible to examine microscopically the 
lymph taken on points for blood discs. Especial care is 
likewise incumbent upon the medical man to see that the 
vaccinifer is free from all syphilitic symptoms, and that 
the vesicle he takes lymph from is quite normal in appear- 
ance. Having pricked the vesicle in several places towards 
the margin, the lymph soon oozes from it, and it is taken 
up on the tip of the point on both sides, care being taken 
not to squeeze the vesicle, but only to take that lymph 
which has come out. A good yielding arm which has been 
vaccinated in five places should serve to charge about forty 
to fifty points. It should be known, however, that the 
first lymph which flows is the most active. A vesicle 
which continues to run with lymph is by no means to be 
exhausted, as the last lymph which flows is only the serum 
of the blood, and it is not to be depended upon to produce 
good results on the children that may be vaccinated with it. 

The points as they are taken should be laid on a piece of 
glass with ground edges, for this can be washed after it has 
been used each time, and thus you can avoid the soiling of 
the points. Keep them free from foreign contamination. 
If they are placed upon wood, or a book, it often occurs 
that they stick when dry owing to a wet portion of the 
point having inadvertently been laid upon them, and when 
it is separated a portion of dirt is pulled off the wood or 
book and adheres to the point. The points are usually 
made from ivory, but there is no reason why other sub- 
stances should not be used. It has often struck us that 
white vulcanite or celluloid might advantageously be used. 
To use the points, one point should be used for each in- 
sertion of lymph. The point should be dipped into cold 
water. All the superfluous water should then be thrown 
off, and the moistened points laid on a piece of glass. This 



THE PRACTICAL DETAILS OF VACCINATION 



81 



should be clone before proceeding to vaccinate with them. 
Next have the individual's arm whom you are about to 
vaccinate got ready. Let the arm be taken out of the 
sleeve as before described on page 71. Hold it in the same 
manner and make your scarification. Then, without letting 
the arm loose from the left hand, proceed to rub the 
lymph off the moistened point over one of the scarifications, 
and so with the rest, using a fresh point for each scarifica- 
tion. It is best not to use the points a second time unless 
you take the trouble of boiling them in water for fifteen 
minutes, which may be conveniently done in a test-tube, or 
in a kettle, taking care that the water boils the whole time. 
They should then be dried between folds of clean blotting- 
paper and put by in a clean stoppered bottle for future use. 
They should on no account be put in the waistcoat pocket. 

The maximum length of time the points will keep 
active is about three months, but they lose their activity 
with age, so that the point of twenty days is less active 
than that of two days. The following table shows our 
experience of them as kept. 

Table II. — Animal Lymph. 

RESULTS OF VACCINATION OF CHILDREN WITH CALF LYMPH 
PRESERVED ON POINTS AND IN TUBES FOR VARIOUS 
PERIODS. 



Mode of 
storage. 



Points 



Tubes 



Time during which lymph 
was stored. 



Under 10 days 
10-20 days 
20-50 days 
50-100 days 
100-154 days 
Over 154 days 
Under 10 days 
10-20 davs 
20-50 days 
50-100 days 
100-154 days 
159-280 days 



Aggregate 
number of 
insertions 
made (5 to 
each child). 



40 
25 
70 
70 
60 
30 
75 
25 
65 
45 
20 
40 



Aggregate 
number of 
successful 
insertions. 



34 
21 
63 
51 
29 

65 
17 
47 
39 
17 
33 



Percentage 
of insertion 
success. 



85 
84 
90 
73 
48 

87 
68 
72 
87 
85 
82 



6 



'82 THEORY AND PRACTICE OF VACCINATION 



Table III. — Stored Calf Lymph when used for the 
Vaccination of Calves. 



Length of time in 
days during which 
lymph was preserved 
in tubes before 


Number of insertions 
made with it on 
calves. 


■■ 

Successful insertions 
on calves. 




Insertion success 
rate, percentage. 


using. 








2 


3,998 


3,390 


84-7 


4 


1,438 


1,139 


74*2 


6 to 8 


255 


184 


721 


9 


431 


309 


71-6 


11 to 12 


337 


273 


70-6 


14 


263 


214 


81-3 


16 


288 


207 


71-9 


17 to 46 


639 


472 


73-8 


53 to 93 


445 


332 


74-6 


100 to 200 


388 


258 


66-5 


200 to 500 


104 


17 


163 


500 to 600 


135 


45 


333 


600 to 700 


82 


24 


35-0 


816 to 858 


72 


4 


5'5 



In comparing the table on pages 79 and 81 of lymph 
preserved in tubes with that of lymph preserved on points, 
it will be noticed that whereas the tube lymph seems to 
gain in activity during the first one hundred days of keep- 
ing, and is less to be depended upon during the early days 
of its preservation, the lymph on the points is most active 
during this period : hence the rule that if you are taking- 
lymph to use immediately or within a month, take it on 
points ; but if you require the lymph for later vaccinations, 
take it in tubes. Always be most scrupulous in recording 
the source of your preserved lymph. This is, of course, 
necessary in all public vaccinations, but it is as morally 
obligatory to you in your private practice. 

Having described the best methods, as far as we know, 
of vaccinating from arm to arm, and with preserved lymph, 
we will next consider the number of places that vaccination 
should be performed in. Evidence has been collected and 
reasons given on pages 7 to 10 showing, we think, the 
greater benefit that is derived from making multiple inser- 
tions, and we have arrived at the decision that five separate 



THE PRACTICAL DETAILS OF VACCINATION 83 



vesicles is the best number to make. That one large 
vesicle having an equal area with the combined areas of the 
separate vesicle is not equally beneficial we consider true 
from the side both of practice and theory. 

In a report of a committee on vaccination to the 
Epidemiological Society, published in vol. v., new series 
of their * Transactions,' p. 163, the committee (consist- 
ing of Mr. Shirley Murphy, Dr. John MacCombie, and 
the author) state that they are disposed to regard 
number and area of scars as by no means convertible 
terms. 

The following consideration will also help to settle this 
question : 

The chemical produced, formed by the growing vesicle, 
is absorbed by the lymphatics, and thrown ultimately by 
the circulation all over the body. Now, the growing- 
portion of the vesicle is its circumference, thus the circum- 
ference is the important part to consider and not the area. 
If, again, as there is every reason for believing, the growing 
vaccine is a form of ferment, a rough analogy will help to 
elucidate this. 

The fermentation of saccharine solutions is brought 
about by an organism called yeast. While this organism is 
growing the process of fermentation goes on, and the sugar 
is converted into alcohol, but as soon as the growth is 
complete, the completed growth ceases to convert the sugar 
into alcohol. Indeed, this completed growth is analogous 
to the completed growth of the vaccine vesicle, which con- 
stitutes its area. In the growing part alone is the product 
produced, and this, as before said, corresponds to the cir- 
cumference of the vesicle. Now, the circumference of a 
circle is slightly more than three times the length of the 
diameter, viz. 3*14159, but it may be taken for all practical 
purposes as three times the length of the diameter; hence, 
if there are five circles of 10 mm. diameter, the circum- 
ferences of these will equal (10 mm. x 3) 5 = 150 mm. in 
length, and 150 mm. circumference will equal a circle whose 

6—2 



THEORY AND PRACTICE OF VACCINATION 



£ diameter is 5 — ' = 50 mm. To re- 

o 

present this graphically let five circles, 
each of a diameter of 10 mm., be drawn 
inside the area of a larger circle, A B 
C D, having a diameter, A C, of 50 mm. 
This is J of the line E C, which repre- 
sents the length of the extended cir- 
cumferences of the five smaller circles. 
The circle, AB CD, will represent the 
size of a single vesicle which would 
have to be made to produce the effect 
- of the five smaller vesicles. It is ob- 
vious that this circle is greater than 
the combined areas of the smaller 
circles. It is, in fact, five times larger. 

The healing of a vesicle the size of 
the larger circle, as every surgeon 
knows, would require a much longer 
time, and while healing would offer 
much greater facility for extraneous 
organisms, such as erysipelas, being- 
developed upon it, than the five smaller 
A circles. 

There can, therefore, 
be little doubt that it is 
better to vaccinate in a 
multiple number of 
places, than to en- 
deavour to make one 
large vesicle equivalent 
to the smaller ones. 

There is one point 
further we may learn 
from the tables to be 
found on pages 33 and 
54 : we can see that the 




THE PRACTICAL DETAILS OF VACCINATION 85 



good we are doing by increasing the number of cicatrices 
is a diminishing one, while the evil that we are doing is an 
increasing one ; so that, in order to do the most good, we 
arrive at a point where the good balances the evil. Mr. 
Marson was of the opinion that the greatest amount of 
good with the least amount of evil was arrived at when 
he made five or six places. We, after a considerable amount 
of practice, have arrived at the same conclusion, so that we 
consider five places as the proper number to vaccinate in. 
Let it be remembered that the people who come up to the 
public vaccination stations are usually of the uneducated class, 
which are numerically the chief opponents to vaccination. 
These people will only have their children once vaccinated 
according to law. It is, therefore, incumbent upon us as 
medical men to give them that kind of vaccination which 
will last them the longest time with the least amount of 
evil, and we have said, after weighing all the evidence we can 
collect, that five is the proper number of insertions to make. 
Among the educated class it is not so incumbent upon us 
to make the larger number of insertions, because there is 
not the same unreasonable opposition to vaccination as in 
the uneducated class, and they will have no objection to re- 
vaccination when it is urged upon them ; but we think it 
right to insist upon the five places among this class also, 
because the better educated class should set an example to 
those who are less fortunate. 

Now, it has been seen that vaccinations performed with 
preserved lymph are not nearly so successful as vacci- 
nations performed with perfectly fresh lymph from arm to 
arm, and it follows that we should vaccinate as far as 
possible from the more active kind of lymph. In a large 
London vaccination station it is possible to keep up a 
constant supply week by week of healthy infants, so also in 
large country towns ; but in the small places a weekly 
supply of healthy children cannot be maintained. In these 
latter places, therefore, the fresh lymph supply will 
frequently be interrupted, and vaccination from preserved 
lymph will often have to be resorted to. 



86 THEORY AND PRACTICE OF VACCINATION 



To obviate this evil as far as possible, it has been 
ordered by the Local Government Board in those dis- 
tricts where the vaccinations are too few to ensure a 
weekly supply of fresh lymph, that the vaccinations be 
done periodically, say every quarter. The first two or 
three healthy children are vaccinated with preserved lymph, 
and from these the number which next comes up to the 
station the following week are vaccinated. It will at once 
be seen that this arrangement offers the minimum amount 
of vaccination with preserved lymph. This regulation 
often appears irksome to those who have not reflected 
upon it. It will be also plain that the regulation enables 
the vaccinator to generate his own supply of lymph, and 
this, of course, is most desirable ; for otherwise very large 
demands would fall upon the central office for the supply 
of vaccine lymph, and this supply would be largely used by 
lazy practitioners, to the detriment of the vaccination of the 
community. There is also a rule insisting that all children 
should be vaccinated at the public stations, and all that 
have been so vaccinated should be inspected at the same. 
This regulation, of course, obviates the evil arising from 
carrying preserved lymph to the houses of patients who it 
may be wished in this way to please. 

We have already spoken of the treatment of the vesicle 
if abnormal, and have cautioned against the use of shields 
(p. 45). When the vesicle is normal only a dry piece of 
clean linen rag should be laid over it and secured in place 
with a few stitches. This should be changed morning and 
night. 

Poultices when ignorantly applied not only cause the re- 
moval of the scab before its time, but produce auto-inocula- 
tion of the surrounding skin. 

There is another bad practice which we have had occa- 
sion to witness several times, and that is, the taking the 
names of the vaccinees on a separate piece of paper, and 
entering them afterwards in the register. No doubt this 
practice has been brought about by the laudatory intention 



PLATE XII. 




West lie wrrLfiuii lath 



PLATE XIII. 




We s t ,Ue wrrLSLTi lith. 



PLATE XIV. 



Fig.l. 




Fiq.2. 




Xe/fc h.ouvuL ensX- 



P| Fig . 4-. 



■fl = 

Table- as, seen- from above wvths i-ox) off. 



7Vest,Newxxxa.n litL 



THE PRACTICAL DETAILS OF VACCINATION 87 



of keeping the register neat, but here neatness is acquired 
at the expense of exactness, and the register had rather 
be exact than neat. We do not mean to imply that 
neatness is not to be aimed at, but only that any method 
by which neatness is acquired should not be one where 
exactness is likely to be sacrificed. Always have the 
register with you, and enter all the names of the vaccinees 
present, before you proceed to vaccinate. It will then be 
easy to enter the source of your lymph supply. Always be 
scrupulously punctual at your station; be firm, yet courteous, 
in your behaviour ; and insist upon vaccinating in the 
manner you consider best. We should always remember 
that it is our duty to educate our patients in professional 
subjects, not for them to educate us. 

We will now consider the modifications of practice we 
have to exercise in animal vaccination. 

First of all let us consider the premises and construction 
of an ideal station, and we here give a plan of such for a 
large station of, say, 7,000 vaccinations a year. 

Secondly, as to the furniture required. For the waiting- 
room about 200 wooden-bottomed chairs, with an equal 
number of wooden stools for nursing mothers to place their 
feet upon, and a good-sized table to place packages, etc., 
with a large umbrella-stand, and perhaps a clock, is all the 
furniture requisite in this room. The floors are best made 
of concrete, without carpet or other covering. 

For the operating-room two tables are necessary, but 
three are more convenient for the vaccination of the calves, 
and a weighing-machine. The construction of these tables 
is shown in the plan, which is drawn to scale. The 
tops are made movable, so that when tilted up the calf 
can be partially secured to it while standing. The top is 
then turned so that the calf lies on the table. The man 
who has helped to turn the table up, and is now placed at 
the back of the animal, seizes the uppermost fore-leg and 
bends it upon itself, holding the bent limb near the body 
of the beast. • This manoeuvre usually renders the beast 



88 THEORY AND PRACTICE OF VACCINATION 



unwilling to struggle, but if it does struggle it gives the 
man great control over it. The head is then secured, and 
the uppermost hind-leg is immediately afterwards fastened 
to the iron upright. But before this is done it is well to 
wrap a piece of saddle stuffing round the leg of the animal 
to prevent the rope and the iron hurting it. The fore-legs 
are then secured by the leather straps, and the calf is ready. 
The other calf is then similarly prepared. As the vac- 
cinated calf will be retained the longer on the table, in 
order to obtain the vaccine lymph, it is humane to put 
this one on the table last. 

The calf to be vaccinated should be shaved previously from 
the umbilicus to the groin, and the shaved portion of the 
skin washed with a piece of sponge soaked in a solution of 
perchloride of mercury, containing one part of perchloride 
to 1,000 parts of water. Two or three grains of chloride of 
ammonium will render the perchloride of mercury more 
soluble, so this salt may be added. The vaccinated animal 
should also be washed over the area on which the vesicles 
are situated with the same lotion, and immediately after 
the lotion with clean water. (The Fig. shows the amount 
of surface shaved, the number of vesicles, and the manner 
of putting on the forceps to obtain the lymph.) After the 
animal is vaccinated, a cradle is placed on its neck as soon 
as it is returned to its stall. The cradle is to prevent the 
animal from licking its vaccinated places. 

The calves should be well fed during the course of their 
vaccination on milk and hay. The milk should be boiled 
and allowed to cool before giving it to the calves. This is 
important, especially during the hot weather, as it prevents 
the diarrhoea, which is so detrimental to the development 
of the vesicles, and is so prevalent among the calves fed 
with raw milk during the hot season. Upon the fourth 
day, but not later than the fifth after vaccination, the 
lymph can be taken from the calves to vaccinate other 
calves or children. In hot weather the earlier day is the 
better. It will be noticed that this is at least three days 



THE PRACTICAL DETAILS OF VACCINATION 89 



earlier than it is customary to take lymph from the human 
infant, which is the eighth. This, indeed, is the latest 
day that it is justifiable for taking the lymph from them. 
Lymph taken from the calf later than the fifth, and from 
the human infant later than the eighth, is not to be de- 
pended upon, for often it will produce sores, if any, which 
are not protective against further vaccination, as in the 
human infant, which has already been shown (p. 57). One 
reason of the more rapid development of the vesicles on the 
calf, probably, is the higher temperature of the young animal 
than of the human infant, the normal temperature of the 
former being 102*63°, whereas that of the latter is only 
98*87°, the difference being 3'76° higher in the calf. The 
chart will show the relative temperatures of the two animals 
during the course of vaccination. 

It will be noticed that the maximum temperature occurs 
on the seventh day in the human infant, whereas it occurs 
on the fourth or fifth day in calves, and this latter fact 
corresponds with the earlier clay on which the lymph is 
better taken from these animals. It is as important to use 
the lymph taken directly from the calf to perform vaccina- 
tion on another calf or on children, as it is to use the 
human lymph taken directly from another arm. When it 
is necessary to preserve animal lymph, it is customary to 
take it either on points or tubes. The same rules as obtain 
in the use of human preserved lymph are applicable to the 
use of animal lymph. If vaccinations are to be performed 
with preserved lymph during the first fortnight of its pre- 
servation, the lymph should be taken on points ; if longer, 
then tubes will give the better result. In using calf lymph 
in tubes it is best to blow out the contents of five or six 
tubes, and mix them altogether. 

The foregoing tables show the relative keeping power of 
the lymph as used for the vaccination of calves or infants. 
A register should always be kept of the names, the 
addresses, the age, the sex, the number of places vaccinated, 
the number of successful places, the source of the lymph 



90 THEORY AND PRACTICE OF VACCINATION 

Chart A. 

SHOWING TEMPERATURE OF VACCINATED CALVES. 

[The continuous line represents the temperature of males, the intercepted 
line that of females.'] 



Days of Vaccination. 






1st. 


2nd. 


3rd. 


4th. 5th. 6th. 


7th. j 8th. | 


eth. | 


10th. | 


Huh. 1 






























































































































































































N 






































































— 








\ 






























































































- 5 













































































































































































































103 
•9 

•a 

■7 

■6 
5 

•4 
3 
2 

•/ 

102 0. 



Chart B. 

SHOWING THE TEMPERATURE OF VACCINATED INFANTS. 

[As regards day of vaccination, temperature taJcen after performance of 

the operation.'] 



Tern p. 
Fahren 
beit. 



Days of Vaccination. 






1st. J 2nd. 3rd. 


4th 


6th. 


Bih. 


7th. 


8th. 


9th. 


10th. 


nth. 














































































































































































































































































/ 


\ 




































































































/ 


\ 


















































































55- 










/ 


























/ 












































\ 


/ 

































































































































THE PRACTICAL DETAILS OF VACCINATION 91 



used, and the date of inspection. The register should 
always be with you while vaccinating, so that the names 
be entered at the time, and the source of the lymph re- 
corded. You should arrange for all those infants who have 
been vaccinated to come back on the day week to the 
station, and it is very useful to make some record of the 
condition of the arm. This is conveniently done by a 
small diagram such as this, i> , where a repre- 

sents the average size of the vesicle, and b represents the 
extent of the areola, if any, on the eighth day. 

You should on no account take the lymph to your 
patient's house, because you will necessarily be using 
preserved lymph, and this should never be used when it 
can be avoided, for failure is so much more frequent after 
its use. All to be vaccinated ought to be made to come up 
to the station at an appointed hour on a certain day, or 
days, of the week, and the vaccinations performed either 
from arm to arm or from calf to arm. If the number of 
cases in a given district be too small to keep up a regular 
weekly supply of fresh lymph, periodical vaccinations then 
are the best, for the first one or two cases can be done with 
preserved lymph and the rest from successful cases of the 
first one or two. 

The following observations may be made during the 
course of a primary human vaccination : 

Days of Vaccination. 
First. 

Notice in some cases, when first vaccinated, the skin at 
the parts scratched immediately seems raised ; this is due 
to a provoked urticara, and is indicative of the tendency of 
the skin to this eruption. 

Second. 

Notice the slight redness at the parts scratched, and that 
they are as yet level with the general surface of the skin. 



92 THEORY AND PRACTICE OF VACCINATION 



The temperature of the individual is scarcely, if at all, 
raised. 

Third. 

Notice that the redness has slightly increased, and that 
the parts inoculated feel shotty. The temperature is a little 
raised. 

Fourth. 

The redness has still further increased ; the points of 
inoculation not only feel shotty, but are slightly raised, 
and are generally commencing to be vesicular. The 
temperature is slightly higher than on the third day. 

Fifth. 

Notice that the inoculated places are distinctly vesicular. 
The temperature remains nearly the same as on the fourth 
day. 

Sixth. 

The vesicles, which now appear, are more or less distinct, 
several of them being crowded over each area of inocula- 
tion. The temperature is further slightly raised. 

Seventh. 

Many, if not all, the vesicles which were crowded over an 
inoculation area have become confluent. The temperature, 
comparatively, is much higher, and has reached its maximum, 
i.e., about J° C. above the normal. 

Eighth. 

This is the usual day for taking the lymph. It may be 
taken before, but not after. The areola begins to form, 
but it never should be excessive. The temperature falls a 
little more than it rose on the seventh day. 

Ninth, 

The areola is now at its height. The temperature again 
rises a little. 



THE PRACTICAL DETAILS OF VACCINATION 93 



Tenth. 

The areola is still extensive, and is not declining. The 
centre of the vesicle is undergoing change, and the vesicles 
are themselves at their maximum size. The temperature 
has fallen. 

Eleventh, 

The areola is fast declining, and the alteration in the 
appearance of the centre of the vesicle is more marked, 
and extending centrifugally. 

Twelfth. 

The areola has almost quite faded, and the scab is 
gradually drying from the centre towards the circumference. 

Twenty-first. 

The scabs usually fall on this day, leaving healthy 
cicatrices, unless they have been interfered with by 
poultices or ointments. 

Concerning Ee-vaccinations, etc. 

Hitherto there has been no satisfactory classification of 
these adopted. One author will give a large percentage of 
these as unsuccessful ; another will give a far less per- 
centage, depending upon what one and another regards as 
successful in the various manifestations of the sore pro- 
duced by a re-vaccination. The following is an endeavour 
to give some scientific classification which shall be regular 
in its working amongst different observers. 

The following classification has been adopted at the 
animal vaccine establishment since its commencement. 

Classification of Ke-vaccinations. 

(0) are those cases on whom re-vaccination produces no 
results. 

(1) are those cases on whom there is scarcely any areola, 
and the sore does not advance after the fourth day, and 
never becomes truly vesicular. 



94 



THEORY AND PRACTICE OF VACCINATION 



(2) are those cases which do not advance after the sixth 
day, become vesicular, and have a moderately extensive 
areola, which has declined by the eighth day. On this day 
the scabs are darkening. 

(3) are those cases on whom there has been a more or less 
extensive areola, which is declining on the eighth day ; by 
this day, also, the vesicles are fully formed, and only 
slightly, if at all, darkening. 

(4) are those cases on whom the areola is at its height on 
the eighth day. 

(5) are those cases on whom the areola, though present, 
has not attained its height on the eighth day. 

(6) are those cases resembling in all respects primary 
vaccination. 

The following Tables IV. and V. have been drawn up, 
showing the practical results of the classification adopted. 

Table IV. contains those cases which have been once 
previously vaccinated, and Table V. contains those cases 
which have been more than once previously vaccinated. 

In Table IV., column 1, are given the characteristic 
numbers of the classification. In column 2 the number 
of cases which fall under the different characteristics is 
given ; in column 3 the range of ages is given ; in column 
4 the aggregate age of all the cases under the specified 
characteristics is given, and the aggregate age divided by 
the number of cases in column 2 will give the average age 
of those re- vaccinated, and they are given in column 5. 

In order to form an approximate estimate of the pro- 
portion of cases which are more or less influenced by 
other causes than by the lapse of time, it is necessary to 
form some idea of the age of presumably normal cases, 
i.e., those on whom time alone influences the return to 
susceptibility. 

Now, it will be seen on reference to Table IV., column 5, 
that 18*08 is the average age at which all are re-vaccinated, 
and, further, that 18 is the age at which those in the mean 
characteristic, or No. 3, are re-vaccinated. It may therefore 



ft X 

H ft 

p CO 
O 

co ft 

CO 

a § 

3 I 



CO 

o 
W 

H 
Q 

. 

„ ft 
co ft 
ft ft 
ft ft 
^ O 
Q 



ft a ft 

ft £ ft 

ft w 

H r H 

co CD o 



• uorjumoouAaj: js.iij ya 9Su <g ^ °° °" J g 
9qj Sutaq pire iba^ut ^oiwJ^wSL 
aStuaAtj u99A\jgq oouojouiq ^ ,_, ,-h ,-h ,-h ^ ,— ■ 


as |Ci 

O !>• 

|t>- 


T^H 


•UOiaiiUIOOBA. 

cui9S9.id ^ oSv qSvxqay 


CO CO OS GO 

CO CM W GO 1 — '1 EC 
H CO CM (M Ol CM CM 


CO 
OS 

CO 
M 


O |CC 
-rfl CO 

CO CO 

CM ICM 


CO 


•uoijbuiooba 

!JU9S9.ld ^TJ 9xh3 9;eS9jSSv 


^H i— 1 CO CO 
O CO O CO 

H lOCOCOO)-f O CO 
00N05OOJ 00 00,(N 
O O CM CO 1— CO O 
t— 1 CM CO O CO © 
t-H ICO 


6758-84 


36782-52 


'M 

T-H 


■»g -pQ ut .I9qranu 01 'P 
ui jgqumu jo sS^ueoxo^ 


CO I— ^H CO CM CM 
CO 00 OS CO CO CM 
CO CM CO -H/l OS | 

CM i L i— I _i_ 1 CO 

\ -f" i 


as 
O 

as 
as 


CM 
CO 

+ 




o 


•psnbg »g *I°0 U I "^ugo J9d 9qj 
93[t)ra oj vi qoQ ui J9qamu 
pojispiopso gqj uiojj pacjOTUcj. 

-qns jo pgppt; oq o% agqumsj 


O CO CO CO VO 
i — I I ^ iO i— 1 *o 

ft ft CM CO CO CM i-l 
, i i CM i— I CO i— 1 

^ + + 1 1 


CO 

CO 

+ 




"Sill ' ZIA 'S9SF0 JO 

.laqumu p3joj oj spsnpiAipui 

pmOIjd90X9 JO 9gB;U90.t9<J 


i — 1 OO CM CO ^t 1 CO CM 
•^H OO CO -1 -rH 1^ CO 

i— I iO r-i CM CO CO 
i— I CM CM 


oo 

CO 


o :>o 

CO 

t-H CO 


e 

as 


"°Z. '[00 «i sqtmpTAip 

-UI p3tlOIjd90X9 JO 9S.3JU90.I9J 


CM O CM CM 

co co oo o co as 

H CO C N CO O) 
OS to CO O CD N OJ 


00 

to 


iun 

o 
o 

ICO 


e 

co 


■sp?npiAipui jbuoij 
-doox9 jo jgqranu p9jt?[nop3Q 


C6 O CO N N H N 
>0 UI H K !>■ 05 

^ O CM ft OS ft CO 
CM CO CM -tf CO CO 
i— 1 CM CM 


763-64 


179-38 


ri 
"?* 

CM 
OS 




quAjgjiu ^DijgqjodA'H 


CM O OO CO ^ CM 
CM CM CM i — l i— 1 >— 1 i- 1 


o 

-as 


cS CO 




CO 


•pjA.X9JUT d8\3X9Ay 


t-h i—i co co r-i as 

HCOlOWCp^O 

w t-h o o as w »o 


as 


? 

as 


8 


•p3A.i9jui sivSdxSSy 


CM CO CM ICM 
OCOOJGOi»ON Ol 

coooascMcoooias 
co as co co io cm o 

CM CO CM jO 


2381-88 






3 to 12 
2 to 36 
•04 to 30 
•02 to 30 

\J £-t \j\J KJ\J 

•04 to 30 
•08 to 41 
•02 to 23 


•02 to 41| 


•01 to 23 


•01 to -41] 


CO 


•S9SB0 jo agqranx 


io m io o o co n co 
co as — 1 as co co ■— i 

CM CO CO |i-H 


co as 

1 CO 

cm|co 


CM 


"SiOG ''VIA 'S9ST3D JO 

jgqrana \v%oi oj spmpiAipui 

I'BUOIjdOOXg JO 9ST3JU90J9J 


1-00 
'75 

1- 91 

2- 89 
4-88 
1-43 


CM 
as 

o 






as 

GO 


■Z "PO UT S9SB0 [own O CD ft 

jo jgqtntui oj spnipiAipui i ccn as ov. o cm t-~ 
pjuoijdooxg jo oStnuocugj mh hcoco 


M 
as 

o 

i-H 




'Gf'BnpiATpUI p3U0IJ ? ( ^T I <? 9 s 

-d9DX9 jo agquinu pgj^nopjQ © =o £ tj (N 

i-h CM 


as 

35 

n 

IT. 






•9Sv p30ij9qjodA"H | ^ °^ ^ S ^ S 1 


1 


CO 


*ogi3 9°iU9Ay 


17- 91 
20-20 

18- 59 
18 

17-05 

19- 27 

20- 79 


18*08 
21-61 


CM 
CO 

00 


IQ 




O lO o 
COOONOOK 

co as as j>- go as cm 

O CM CO t-h CO CM o 

co o io o as co t-h 

(N N CO O ^ N H 
H CO CM 


CO 

M 

CO 

oo 
a. 


81257 


CO 

CO 
00 

a. 

OS 

as 
ia 

c 

H-3 
* 


^H 
CO 


•sgSB jo oSubh 


2 to 65 
5 to 65 

3 to 75 

4 to 60 
3 to 59 

1-6 to 61 
7 to 52 
1-6 to 75 


•4 to 36 


•S9SB0 jo .igqum 


to CO N OO CO O CO lO 

lO^Hascocoaso 
t-h co as co ^ co o 

1— 1 i-H O 


CO 
CO 


l ° CM 


usqumu oijsi.igjoiU'Bqr} 


(O KJ Ttl CO CM H O 








c 
o 



96 THEORY AND PRACTICE OF VACCINATION 



be inferred that No. 3 contains very few, if any, of the 
abnormal cases. It may also be inferred that the two 
characteristics on either side of 3, i.e., characteristics Nos. 2 
and 4, will contain fewer of the abnormal cases than those 
more remote from 3 ; yet we may safely assume that they 
will contain some. No. 2 is *95 less than 18, and No. 4 is 
•59 greater than 18, or on an average *77 difference ; the 
allowance must be made for the abnormal cases they 
contain. Let it be assumed that the figure *77 may be 
taken as 2, and let it also be assumed that the charac- 
teristics are regular, i.e., they represent equal increments 
of time that would elapse before each consecutive charac- 
teristic would be reached on the return to susceptibility. 
Then, on making additions of 2 to 18 as the characteristic 
numbers ascend, and deductions of 2 as they descend, we 
get 20, 22 and 24 on the one hand, and 16, 14 and 12 on 
the other. These may be called hypothetical ages, and 
they are given in column 6. From the above considera- 
tions it follows that if time alone had to be considered, an 
individual is by a single infantile vaccination rendered 
immune to further vaccination for fourteen years. As 6 
represents the re-vaccination, which resembles in all respects 
a primary vaccination, the individuals which have the 
greatest tendency to return to their susceptible condition 
will be collected together under this class. They may be 
called unstable with respect to their former vaccination. 
The number of the unstable individuals will gradually 
diminish in the characteristic as No. 3 is approached. 

Again, as represents that no result follows re- 
vaccination, all the individuals which have an opposite 
tendency to those just mentioned, and who may be called 
the stable individuals, will be collected under that character- 
istic. These, it may be inferred, will gradually diminish as 
No. 3 is approached. The unstable individuals will tend 
to diminish the average age, while the stable individuals 
will tend to increase it to what it would have been if time 
alone had to be considered. 

In characteristics Nos. 6, 5, and 4, containing as they do 



THE PRACTICAL DETAILS OF VACCINATION 97 



the majority of the unstable class, this unstable class must 
be subtracted in order to raise the average up to the hypo- 
thetical ages ; but in characteristics Nos. 2, 1, and 0, con- 
taining the stable class, unstable cases must be added in 
order to bring down the average to the hypothetical age. 
For, as we have just said, the inclusion of unstable cases 
diminishes the average age, 5*59 years being the average 
interval which elapses between one re-vaccination and 
another, as given in Table V., column 5a. And as we may 
fairly assume the cases under this characteristic are, the 
vast majority of them, stable individuals, we may approxi- 
mately take 5*59 years as the average period during which 
the stable individuals enjoy immunity. 

From the above data we can formulate the following 
equation for characteristic 6. 

Let x represent the number of unstable individuals, 
which must be subtracted from the number in column 2, 
i.e. 156, in order that the average age given in column 5, 
i.e. 17'91, may be brought up to the hypothetical age given 
in column 6, i.e. 24. 

Hence x x 5*59 {i.e., x multiplied by the average period 
during which the stable individuals have immunity, for 
this at most must be the longest average time that unstable 
individuals have immunity) will give approximately the 
aggregate age of the unstable individuals ; and if we take the 
number from 2806* 3, the aggregate age of all the cases 
given in column 4, we get 2806*3 — 5*59 x, and this divided 
by 156, the total number of cases less by x, will give us 
the average age of those who are only influenced on their 
return to susceptibility by time, and this we have assumed 
to be 24. The equation will therefore stand thus for 
characteristic 6 : 

2806-3 - 5-59 

156-.* ~ 24 ' 



2806-3 - 5-o9x = 3744 - 24*. 
18-41* = 937-7. .-. * = 50-93. 



7 



98 THEORY AND PRACTICE OF VACCINATION 



The equation for No. 5 will be : 

7029-5-59, 



848 -a; ~ 22 - 

7029 - 5'59, = 7656 - 22,. 
16-41, = 627. .-. , = 38'23. 



The equation for No. 4 will be : 

18539-75-5-59, 



997-, = 20 ' 

18539-75 - 5-59, = 19940 - 20,. 
14-41, = 1400-25. .-. x = 97-17. 



No. 3, it has been assumed, contains no exceptional cases. 

No. 2. Here we have to add unstable cases in order to 
diminish the average age and make it equal to the hypo- 
thetical age. 

Our equation for this characteristic will be : 

24938-7 + 5-59, 

1463 + , ~ 6 * 

.-. 24938-7 + 5-59, -=23408 + 16,. 
.-. , = 147*04. 



Similarly the next equation for No. 1 will be : 

7629 + 5 59, 
396 + , ~ 14 ' 

.*. 7629 + 5-59 = 5544 + 14,. 

.-. 8-41, = 2085. .-. , = 247-92. 



Similarly the next equation for characteristic will be : 



1 102 + 5- 59, = - 2 
53 + , 

1102 + 5-59, = 636 + 12,. 
6*41, = 466. .-. , = 72-70. 



The different values that have been found for x are given 
in column 7, and they represent the number of exceptional 
cases which are contained under the different characteristics, 



THE PRACTICAL DETAILS OF VACCINATION 99 



and these are what were required to be found. It will be 
noticed that their sum is 653'99, and as there are 5,075 
cases, the percentage of exceptional cases will be 12*89. 

In column 8 the percentages that the calculated numbers 
in column 7 bear to the number of cases in column 2 are 
given under their respective characteristics, and in column 9 
the percentages that the calculated numbers in column 7 
bear to the total number of cases — viz., 5,075 — are given. 

Table V. — This table contains those cases which have 
been more than once previously vaccinated. Columns 2a, 
3a, 4a, 5a, 6a, la, 8a, and 9a correspond, giving the same 
details as columns 2, 3, 4, 5, 6, 7, 8, and 9 do in Table IV. 

The equations for Table V. require the negative sign 
throughout, because the hypothetical intervals are all higher 
than the average intervals. It will also be noticed that the 
percentages of the exception cases to the numbers in 
column 2a, which are given in column Sa, are more nearly 
equal than they are in the corresponding column 8 in 
Table IV., except for characteristics 6 and 0. The probable 
reasons for their exception will presently be given. The 
meaning of this generally greater equality of the per- 
centages in column 8a is probably that the element of time 
has correspondingly less to do with the return to suscepti- 
bility in the cases of persons who have been more than 
once vaccinated than it has to do with those only once 
previously vaccinated in infancy. If this be so, then, since 
the element of time is more or less eliminated for those 
in Table V., there can be no reason why proportionally 
more stable individuals should be re-vaccinated at the later 
intervals of time than at the earlier ; neither should there 
be proportionally more of the unstable individuals re-vacci- 
nated at the earlier intervals. Hence, the proportion of 
the exceptional individuals to the number of cases given in 
column 2a ought to be about the same if the registration 
under the different classes be correct. There is indeed 
sufficient equality to show that registration was practically 
correct, except, as has been said, for characteristics 6 and 0. 

7—2 



ioo THEORY AND PRACTICE OF VACCINATION 



With regard to characteristic 6, it can be seen in Table V. 
that there are only five out of 1,113 cases, or only 0*45 per 
cent., and it is more than likely that there may be some 
whose alleged former re-vaccination was not really success- 
ful. Then, again, with regard to characteristic 0, some of 
the cases were probably successfully re-vaccinated, but the 
re-vaccination had run so rapid a course that on the eighth 
day, when inspected, it was considered that they had not 
taken ; further, those individuals who are judged not to 
have taken are entered as fresh re-vaccinations in the register, 
and nearly always the same results happen again on the 
next eighth day, when they are inspected. As these cases 
are vaccinated three times, it follows that the number of 
cases — viz., thirty-seven — ought to be divided by three, 
which would leave only 12*5 cases out of 1,113, or 11*23 
per cent. That the registration was practically correct is 
further borne out by the fact that there really were two 
registrars : one, Mr. Lapidge, at Southampton Row, who 
registered 333 cases ; the other, Mr. Adams, at 95, Lamb's 
Conduit Street, who registered 780 cases. Tables VI. and 
VII. show the similarity of the two registrations respectively, 
and Table VIII. compares the two comparable columns. 

Column 10, Table V., contains the number of cases which 
must be added or subtracted from the calculated numbers 
in column la to make the percentages in column Sa equal. 
The calculation is thus made : Let x = the number to be 
added or subtracted from 4'59, so as to make the per- 
centage in column 8a equal to 68*7, which is the average 
percentage in column 8a. 

Thus, for No. 6 characteristic the following equations 
can be formulated : 

(4-59 ^^)100 = 68 . 7< 

5 

.-. 459 ±100* = 343-5. 
.•. x = ± 1*15 ; and by trial we find that x = - 1'15. 

Similarly, the equation for No. 5 characteristic will be : 

(2Q*;)ioo = 68 . 7 , ,. X = + V11 . 

OO 



THE PRACTICAL DETAILS OF VACCINATION 101 

Similarly, the equation for No. 4 characteristic will be : 

( 62-53^)100 = 6g , 7 _ ,^ = + 2 . 73 _ 
95 

Similarly, the equation for No. 3 characteristic will be : 
(124-17^)100 = 6g , 7 . x= - +23 . 53> 

Similarly, the equation for No. 2 characteristic will be : 

( 2 49-7^x ) 100 = 68 , 7 ,, = + 18 . 16 . 
o90 

Table VI. 



CASES MORE THAN ONCE RE-VACCINATED AT SOUTHAMPTON ROW, 
1884 TO 1885, REGISTERED BY MR. LAPIDGE. 



Characteristic numbers. 


Number of cases. 


Range of intervals. 


Aggregate interval. 


Average interval. 


Hypothetical interval. 


Calculated nvimber of 
exceptional cases. 


Percentage of excep- 
tional cases to numbers 
in Column 2. 


Number to be added or 
subtracted from the calcu- 
lated numbers in Column 7 

to make the percentage 
equal in Column 8. 


Percentage of numbers 
in Column 9 to those in 
Column 2. 


6 
5 
4 
3 
2 
1 



2 
10 
17 
61 
88 
134 
21 


3 to 7 
3 to 36 
3 to 30 
1 to 33 
16-30 
•08 to 15 
•02 to 23 


10 
121 

185 
690 
951-41 
1086-6 
123-27 


5 
121 

10- 82 

11- 32 
10-81 

811 
5-87 


24 
22 
20 
18 
16 
14 
12 


2 

6-14 
10-97 
33-63 
45-07 
97-10 
21 


100 
61-4 
64-53 
55-13 
51-22 
72-46 

100- 


-•70 
+ •344 
+ -0528 
+ 5-92 
+ 11-99 
- 10-21 
-7'38 


-35-16 
+ 3-44 
+ •31 
+ 9-7 

+ 13-62 
-7'62 

-3514 




333 


•02 to 36 


3167-28 


9-51 




215*91 


64-84 





1 


? 


70 


•02 to 25 


612 


8-74 


Mean 
taken. 

18 


53-39 


76-27 


-8 


-11-43 




403 


•02 to 36 


3779-28 


9-37 


18 


286*46 


71*08 








Cols. 1 


2 


3 


4 


5 


6 


7 


8 


9 


10 



102 THEORY AND PRACTICE OF VACCINATION 

Table VII. 



CASES MORE THAN ONCE RE-VACCINATED AT LAMB'S CONDUIT 
STREET, 1882 TO MARCH, 1895, REGISTERED BY MR. ADAMS. 



Characteristic number. 


Number of cases. 


Range of intervals. 


Aggregate interval. 


Average interval. 


3 
> 

u 

44 

a 
"3 

o 

o 
P< 

w 

24 
22 

90 

18 
16 
14 

12 


Calculated number of 
exceptional cases. 


Percentage of excep- 
tional cases to number 
in Column 2. 


Number to be added or 
subtracted from the calcu- 
lated numbers in Column 7 
to make the percentages 
in Column 8 equal (58 '59. 


05 fl 

2 ® 
Si 

a <** 
CS fi 
°c. S 

IP 

o rs 

2o 
Pi .5 

- 14-08 
+ 5-35 

"T O OO 

+ 10-33 
+ 2-68 
-11-71 
-31-37 


6 
5 
4 
3 
2 
1 



3 
23 
78 
154 
302 
204 
16 


6 to 12 
2 to 23 
•04 to 28 
•02 to 30 
•04 to 30 
•08 to 24 
•25 to 22 


255 
262 
814 

1639-52 
2688-49 
1419-88 
83-75 


8-5 
11-39 
10-44 
10-65 
8-90 
6-96 
5-23 


2-48 
14-55 
50-51 
88-68 
199-03 
163-81 
1599 


82-6 

63- 26 

64- 76 
57-61 

65- 9 
80-30 
99-94 


-•42 
+ 1-23 
+ 2-99 

+ 16-91 
+ 811 

- 23-89 
-502 


Total 


780 


•02 to 30 


6932-64 


8-88 




556-64 


71-36 






? 


186 


•01 to 33 


1769-88 


9-52 


Mean 
taken. 
18 


123-58 


66 44 


+ 10-99 


+ 5-91 


Total 


966 


•01 to 33 


8702-52 


901 


18 


758-58 


78-53 




Cols. 1 


2 


3 


4 


5 


6 


7 


8 


9 


10 



Table VIII. 



Charac- 
teristic 
number. 


Numbers to be 
added or subtracted 

from Column 7, 
Table III., to make 

the percentages 
in Column 8, 

Table III., equal. 


Numbers to be 
added or subtracted 

from Column 7, 
Table IV., to make 

the percentages 
in Column 8, 

Table IV., equal. 


Percentage of 
characteristic 

number to 
total number 
of cases. 


Percentage of 
characteristic 

number to 
total number 
of cases. 




Lapidge. 


Adams. 


Lapidge. 


Adams. 


6 


-35-16 


-14-08 


•6 


•38 


5 


+ 3-44 


+ 5-35 


3-00 


2-95 


4 


+ •31 


+ 3-83 


5-10 


10- 


3 


+ 9-7 


+ 10-33 


18-32 


19-74 


2 


+ 13-62 


+ 2-68 


26-42 


38-72 


1 


-7-62 


-11-71 


40-24 


26-15 





-35-14 


-31-37 


6-31 


2-05 



THE PRACTICAL DETAILS OF VACCINATION 103 



Similarly, the equation for No. 1 characteristic will be : 
( 264-71±,)100 = 68 . 7 _ .,, = _ 32 ... 

COO 

Lastly, the equation for characteristic will be : 
(36-97^)100 = 68 , 7 . ,., = -11-55. 

The different values found for x — and these represent the 
numbers that have to be added or subtracted from the 
number in column la to make the percentages in column 
8a all equal — are given in column 10. 

In column 11 the percentage of the numbers in column 10 
to the number of cases contained in column 2a is given. 

In column 12 the aggregate age of all the cases under 
the several characteristics is given for the present re-vacci- 
nation. 

In column 13 the average age is given, found, of course, 
by dividing the aggregate age by the number of cases in 
column 2a. 

In column 14 the difference between the average age in 
column 13 and the average interval in column 5a is given, 
and this must necessarily be the average age at which the 
first re-vaccinations took place. 



LECTURE VI. 



ON THE RELATION OF COW-POX, HORSE-POX, AND CAMEL-POX 
TO SMALL-POX. 

The view that cow-pox and horse-pox are simply modifica- 
tions of human small-pox, and owe, not only their origin, but 
their continued existence to it, is one which has commended 
itself to many since Jenner's time, for it accounts readily 
for most of what may be called the peculiarities, both of 
cow-pox and horse-pox, and it saves us from many diffi- 
culties which meet us on the contrary supposition, viz., that 
cow-pox is an independent disease. 

A good instance of these difficulties, and how they are 
met, is seen in Dr. Ballard's prize essay on vaccination,* 
pp. 32, 33, where he, while admitting that the cow can be 
inoculated with small-pox virus, and that the lymph collected 
from the resulting vesicles is so modified that it no longer 
produces small-pox but only cow-pox, yet explains it on the 
hypothesis that they are independent diseases, by supposing, 
on the one hand, that the cow is incapable of developing 
small-pox, therefore when the cow is inoculated with small- 
pox virus it is cow-pox which is produced ; on the other 
hand, he supposes that man is capable of developing both 
his own special disease, small-pox, and the varioloid disease 
of the cow. Hence that cow-pox, however arising in the cow, 
whether by the direct inoculation of small-pox virus or by 

* 'Vaccination, its Value and Alleged Dangers,'] a prize essay, by 
Edward Ballard, M.D., 1868. 



THE RELATION OF COW-POX TO SMALL-POX 105 



some other occult manner, remains cow-pox always when 
again transmitted to man. 

A right understanding of this matter is one of great 
practical importance, for if it be true that cow-pox is but 
modified small-pox, then no longer must we regard the 
human body as a soil foreign to the vaccine virus, but 
rather the cow's, and thus a weighty argument now used 
in favour of animal vaccination would have to be transferred 
to the opposite balance. One instance may be given of 
how the view that vaccinia is an independent disease 
operates. Dr. Ballard, in the work already referred to, 
on p. 241, speaking of the care to be taken in selecting 
cases for vaccination, says : ■ He (the vaccinator) should 
remember that the vaccine disease is one which is not 
natural to man, that it is planted on a soil to which it is 
foreign, and that it requires constant watchfulness and 
judicious cultivation to restrain its inherent disposition to 
deteriorate.' This passage clearly shows Dr. Ballard's 
view of cow-pox, and helps to explain his advocacy for 
animal vaccination on p. 253. 

The arguments which may first be brought forward in 
favour of the view of the direct relation between cow-pox 
and small-pox are those derived from the special charac- 
teristics of cow-pox in the cow when compared with small- 
pox in man. It is generally admitted that the cow-pox is 
propagated among the cows by milking, and those who have 
paid most attention to the subject are agreed that it is never 
transmitted from one animal to another except by direct con- 
tact. The disease is never, like small-pox, conveyed by ex- 
halations, i.e., through the medium of the atmosphere. Thus 
it is only milch coivs that suffer during epidemics. Jenner 
was convinced of this. On p. 86 of his ' Inquiry into the 
Causes and Effects of Variola Vaccinia,' published in 1801, 
he writes : ' It has been conceived to be contagious among 
cows without contact, but this idea cannot be well founded, 
because the cattle in one meadow do not infect those in 
another — although there may be no other partition than a 



io6 THEORY AND PRACTICE OF VACCINATION 



hedge — unless they be handled or milked by those who 
bring the infectious matter with them ; and, of course, the 
smallest particle imaginable, when applied to a part 
susceptible of its influence, may produce this effect.' Ceely, 
also, in his ' Observations on the Variola Vaccinias,' published 
in 1840, from the Transactions of the Provincial Medical and 
Surgical Association, writes : ' It is considered that the 
disease is peculiar to the milch cow, that it occurs primarily 
when the animal is in that condition, and that it is casually 
propagated to others by the hands of the milkers. ... I 
have frequently witnessed the fact that sturks, dry heifers, 
dry cows, and milch cows milked by other hands, grazing 
in the same pastures, feeding in the same sheds, and in 
contiguous stalls, remain exempt from the disease.' 

Both the above observers, then, agree in thinking the 
disease is seldom, if ever, conveyed from one animal to 
another except by direct contact. 

Another fact may be mentioned here, showing, as far as 
it goes, the same thing. During the practice of animal 
vaccination there is not, as far as is known, a single 
instance on record of one animal becoming affected from 
another except by direct inoculation. There certainly has 
not been one at the Animal Lymph Establishment at 
Lamb's Conduit Street since it was opened in 1882, and 
during this time, up to July, 1895, there have been upward 
of 3,300 calves vaccinated there, and not one of them has 
been affected except by direct vaccination. Now, since in 
animal vaccination the true cow-pox, unmodified by trans- 
mission through man, is conveyed, this fact is of some sig- 
nificance. 

It will scarcely be necessary to consider further evidence 
on this point, as no observations tend to the contrary con- 
clusion, except some experiments made in India in 1832, of 
which notice will be taken further on. 

How, then, does the disease arise ? Jenner suggests its 
origin from the sore heels of horses, and no one reading 
his work will think that he arrived at this conclusion with- 



THE RELATION OF COW-POX TO SMALL-POX 107 



out due observation. This opinion of his, it is true, is 
no longer entertained, partially because the variolous affec- 
tion of the heels has been ignorantly confounded with the 
grease, and partially because the explanation does not 
account for the origin of all cases of cow-pox ; but that 
this is the way in which the disease has occasionally been 
communicated to the cow seems more than probable. 

Other observers, such as Ceely, offer no explanation of 
the origin of cow-pox. Before reflecting further upon the 
above peculiarity of cow-pox, it will be convenient to con- 
sider another, and that is, its localization to the udder and 
teats. All observers are agreed upon this point. The 
disease is conveyed by the milkers to the udder and teats, 
on which vesicles are formed, but the vesicles appear on no 
other part of the body. For the conveyance of the disease, 
it is known that the healthy hand is quite as efficacious as 
when it is itself affected. 

Horse-pox seems also to have both the above-mentioned 
peculiarities of cow-pox, the only difference being that in 
the horse the disease is localized at the heels instead of at 
the udders. Horses, however, often inoculate the mouth 
and the mucous membrane of the nose by biting their 
already affected and itching heels.* The mouths of the 
horses are always affected subsequently to their heels. 

Horses suffer quite as much as mares do from the disease, 
whereas in cow-pox the milch cows alone are affected. 

It is stated that in Asia, in the province of Lus, the 
milkers have a disease long known as photo-shooter, con- 
tracted from milking the camel in the same way as cow- 
pox is contracted in milking the cow, and that it has been 
found to be equally protective against the small- pox. t 
Now, it is very remarkable that the cow and horse and 
camel should each be liable to a disease (producing vesicles 
so like those of small-pox, and that the lymph from them, 

* Seaton's ' Handbook of Vaccination,' p. 27. 

t Article, by A. W., in Once a Week, July 4, 1863, p. 36. 



108 THEORY AND PRACTICE OF VACCINATION 

when used on man, protects him from small-pox) on those 
parts of their bodies which are brought into contact with 
the hand of man. It thus seems likely that if cows and 
camels were not milked, and horses were not shod, their 
respective varioloid diseases would cease, as far as we can 
see, to exist. Moreover, the parts of the respective animals 
which are affected are those very parts which are chiefly 
handled frequently by man. In order to account for the 
continuance of the disease, it seems necessary to suppose 
that it is a derivative from small-pox, and, consequently, 
that if small-pox became extinct, cow-pox, horse-pox and 
camel-pox would cease to exist. This supposition obtains 
much support when we find that cow-pox has become much 
less prevalent ; and this is remarkable, for we should have 
expected that with the general distribution of cow-pox virus 
over the land for the purposes of vaccination, cow-pox, if a 
disease per se, would have increased rather than diminished. 
That cow-pox does prevail chiefly during great epidemics of 
small-pox, and that it is more rare now than formerly, are 
facts generally admitted ; however, the following reason for 
thinking so may be given. 

From 1838 to 1841, cow-pox seems to have again been 
frequent in England. It was during these years that most 
of the new stocks of vaccine lymph arose. Mr. Estlin met 
with the disease in Gloucestershire and raised a fresh stock 
of vaccine lymph. Mr. Fox and Mr. Sweeting also met with 
the disease in Dorsetshire, and raised lymph stocks. 

Dr. Seaton, in his ' Handbook of Vaccination,' p. 414, 
remarks concerning this : ' It is certainly very singular that 
it (cow-pox) should have been seen by so many observers 
about the time, and it deserves particular notice that this 
was at a period when one of the most formidable epidemics 
of small-pox that has occurred in the present century was 
sweeping over the land.' 

On reading Jenner's treatise ' An Inquiry into the Causes 
and Effects of the Variolse Vacciniae,' one is at once struck 
with the frequent occurrence of the disease in Jenner's 



THE RELATION OF COW-POX TO SMALL-POX 109 



immediate neighbourhood, viz., Berkeley in Gloucestershire. 
He mentions it incidentally as occurring 



In 1759 on page 47 ... 


... 2,596 deaths from small-pox in London 


„ 1760 


13... 


... 2,187 




,, 1765 


11... 


... 2,498 


>) 


„ 1770 


9... 


... 1,986 


)j 


„ 1780 


20... 


871 


»» 


„ 1782 


„ 22, 23 ... 


636 


»» 


„ 1791 


21... 


... 1,747 


?> 


„ 1794 


„ 21... 


... 1,913 


>> 


„ 1796 


„ 15, 16 ... 


... 3,548 




„ 1798 


47... 


... 2,237 





Besides these incidental references, we have this notable 
passage on page 47, from which we may infer that cow-pox 
was then almost of yearly occurrence. Having broken off 
his observations on the disease in 1796, he writes in 1801 : 
' The spring of the year 1797, which I intended particularly 
to have devoted to the completion of this investigation, 
proved, from its dryness, remarkably adverse to my wishes ' 
(this year 1797, it may be permitted to remark, was one 
remarkably free from small-pox in London : there were 
only 522 deaths in the year, and there had not been so few 
deaths since the year 1702, i.e., for a period of ninety-seven 
years) ; ' for it frequently happens while the farmers' horses 
are exposed to the cold rains which fall at this season, that 
their heels become diseased, and no cow-pox then appeared 
in the neighbourhood.' The disease, however, did appear 
the following year, viz., in 1798, a year in which small-pox 
in London was prevalent, there being 2,237 deaths. 

Nobody at the present time would confidently look forward 
to the return of cow-pox in order to complete observations 
commenced the previous year. Concerning the rarity of the 
disease in 1840, Mr. Ceely, in discussing Dr. Sonderland's (of 
Bremen) article in the Medical Gazette * November 9, 1831, 
says on page 94 of his work, ' Observations on the Variola 

* See extract in Medical Gazette, November 9, 1831, taken from 
Journal des PraMischen Heilkunde, January, 1831. 



no THEORY AND PRACTICE OF VACCINATION 



Vaccinia ' : ' The result of careful and extensive inquiry 
induced the belief that the asserted comparative rarity of 
the disease was true as regarded this neighbourhood.' On 
page 47 he says : ' I am inclined to believe, from all the 
information I have been able to procure, that cow-pox is 
not so often met with as it was forty or fifty years ago ; 
but upon this point I speak with much hesitation.' Mr. 
Ceely, be it remembered, was then writing at a time when 
cow-pox was more prevalent at Aylesbury than it had been 
for some years past, and than it has been since. 

Horse-pox also seems liable to prevail during epidemics of 
small-pox. In the account of the disease at Eieumes in 
1860, it is expressly stated that human small-pox was very 
prevalent at the time. (See Ballard Prize Essay, p. 32.) 

Now, it appears likely, since small-pox and cow-pox are 
so similar — if not directly related — that the same conditions 
existing at certain times would be favourable to the spread 
of both diseases, and this might be given as a reason for 
the prevalence of the two together ; but against this we 
may reasonably suppose that if it had not been for vaccina- 
tion, epidemics of small-pox would have been more widely 
spread than they have been during this century (see Dr. 
Ballard's Prize Essay, p. 71 et seq.). But where, then, are 
the corresponding epidemics of cow-pox, which should have 
occurred if cow-pox be an independent disease ? They also, 
together with the small-pox epidemics, have decreased. It 
has been urged that the milkers are now all vaccinated, and 
therefore are less likely to become affected with the natural 
disease, and therefore do not so readily convey the disease ; 
but this cannot be the explanation, for the healthy hand 
seems to convey the disease from one animal to another 
quite as readily as the affected hand ; besides, the disease 
must incapacitate those suffering from it from doing their 
work as milkers — at all events, for some time during its 
progress. This, however, is beyond the point, for it is not 
contended that the disease spreads less on a farm now than 
formerly, but that for years together it does not exist at all. 



THE RELATION OF COW-POX TO SMALL-POX in 



But besides the indirect evidence given above, there is 
positive evidence to bring forward to show that small-pox 
may be communicated by inoculation to horned cattle, and 
that the resulting vesicles yield lymph having all the 
properties of vaccine lymph. In other words, small-pox, by 
one transmission through an animal, becomes modified, so 
that it is not only no longer infectious, but also is limited 
as regards the eruption to the points of inoculation. 

This, indeed, is not a unique experience in pathology, 
for in anthrax we have an analogous example. Anthrax, as 
is well known, is a very fatal and infectious disease among 
horned cattle. If a mouse is inoculated with the disease, 
as it may readily be, it dies ; but if a healthy animal such 
as a sheep or ox be inoculated from the mouse, it produces 
a local sore on the sheep or ox which does not prove fatal, 
and subsequently protects it from the virulent form of the 
disease. Here the mouse in anthrax takes the place of the 
cow in small-pox. In both cases the virus is altered : from 
being virulent, it becomes benign. 

Dr. Gassner,* of Gunzburg, so early as 1801, succeeded 
in inoculating a cow on the eleventh experiment with the 
small-pox virus, and used the lymph thus obtained for 
vaccinating four children, and from them seventeen others. 
No small-pox appeared among these children. In 1836, 
and again in 1838, Dr. Theile, of Kasan, succeeded in 
inoculating the cow with small-pox matter, and he used the 
lymph for the vaccination of children. He thus states his 
conclusions on this point : 

' 1st. The so-called vaccine is not an eruptive disease 
peculiar to the cow, but is produced in it by the transmis- 
sion of human small-pox to it ; and the man, and not the 
cow, as has hitherto been thought, is the source of the 
disease. 

' 2nd. The mild disease thus caused in the cow can, by 
direct transmission from the cow r to man, produce in him 

* Heine in Henke's Zeitschr. Erganzungsclirift, xxx,, p. 57 ; also 
British and Foreign Medical Beview, January, 1840. 



ii2 THEORY AND PRACTICE OF VACCINATION 

as mild a disease, which gives protection against the natural 
small-pox.' 

His other conclusions refer to an artificial method of pro- 
ducing this modification in small-pox virus without the aid 
of the cow. This he thought he did by preserving small- 
pox virus for ten days between two pieces of glass, and 
then diluting it with milk, and using this mixture for 
vaccinating children. The lymph obtained from the 
resulting vesicles he again kept, and diluted with milk as 
before. After ten generations the lymph had become 
modified, and could be used without the addition of milk.* 
Mr. Ceely, in 18B9, also succeeded in inoculating cows with 
small-pox, and found that the resulting lymph caused a 
disease identical with vaccinia. His experiments were pub- 
lished in the eighth volume of the Transactions of the 
Provincial Medical and Surgical Associations, and also in 
a separate work, entitled ' Observations on the Variola 
Vaccinia,' 1840, Worcester. In a note, on p. 140 of the 
latter, which is quoted to show that his experiments were 
independent of Dr. Theile's, he says : " But I am gratified 
to learn that since the announcement of those [experi- 
ments] which I have just detailed, intelligence has been 
received of the success of Dr. Basil Theile, of Kasan, in 
Bussia, in similar experiments.' 

He also, on the same page, states that when he wrote 
more than 2,000 subjects had been vaccinated with his 
variola vaccine lymph. About this time also Dr. Beiter, of 
Munich, succeeded. He had failed previously, but having 
adopted the method of inoculation practised by Dr. Theile, 
he succeeded. 

In 1840, Mr. Badcock, then a chemist in Brighton, 
succeeded on his first attempt, and afterwards succeeded 
some thirty or forty times ; nevertheless, his success only 
amounted to about 7 per cent, of his trials.! Some of the 

* Henke's Zeitschrift fur die Staatsarzneikund, 1839. 
•j- ' Details of Experiments Proving the Identity of Cow-pox and 
Small-pox,' Brighton, 1845. 



THE RELATION OF COW-POX TO SMALL-POX 113 



lymph thus obtained by Mr. Badcock furnished the stock 
which was used at the Highgate Small-pox and Vaccination 
Hospital for some fifteen years or more by Mr. Mar son. 

Dr. Vy,* of Elburg, in 1867, also succeeded, and used the 
lymph for vaccination. Most, if not all, experimenters who 
have succeeded agree that there is considerable difficulty in 
obtaining a characteristic pock on the cow from inoculation 
of small-pox ; and, indeed, there are not a few who have 
entirely failed. 

Mr. Marson tried forty times in succession without 
result. Coleman, King, Dalton, Sacco, Fiard, and Bous- 
quet all failed; but M. Chauveau, and associated with 
him MM. Yiennois and Meynet, who called papular tume- 
faction a success, succeeded every time, and from these 
papules they produced small-pox. Small-pox is also said 
to have resulted from experiments similar to those of 
M. Chauveau at Boston, U.S., and also at the Veterinary 
School of Berlin.f 

In these experiments, however, there is no evidence to 
show that the original small-pox virus, with which the 
scratches were deluged, may not have been taken up again 
and used unchanged for the inoculation rather than the 
vaccination of children. 

On November 18, 1885, Dr. Simpson, then of Aberdeen, 
sent me fifteen charge points to Lamb's Conduit Street, 
with the following history : 

He had obtained some small-pox lymph from an un- 
vaccinated female, F. P., aged 13, (a) on the fifth day of 
eruption, and (b) on the sixth day of eruption. On the 
eleventh he inoculated a cow with the small-pox lymph on 
one teat with one scarification from the lymph which had 
been taken on the fifth day of the girl's eruption, and on 
another teat with two scarifications from lymph of the sixth 
day of eruption. 

* Bulletin de V Acad, de Med., t. xxxi., p. 430. 
f See Seaton's ' Handbook of Vaccination,' p. 55. 



ii4 THEORY AND PRACTICE OF VACCINATION 



On November 17, the seventh day afterwards, the single 
scarification yielded the fifteen points which were sent to 
Lamb's Conduit Street. 

The two scarifications done with the sixth-day small-pox 
lymph only became papular. 

The lymph on the fifteen points was used at Lamb's 
Conduit Street on November 21, 1885, for the inoculation 
of a male calf (938), aged about 6 months, in five incisions, 
three of which had taken, and were vesicular on November 26. 
From this calf, whose vaccine vesicles so exactly resembled 
the current vesicles, a child and another calf (941) were 
vaccinated, the child in five places, the calf in seventeen. 
The child was kept under observation, and it went through 
a course of normal vaccinia. No eruption occurred, and no 
small-pox was communicated to others. Calf 941 was 
successful in six out of the seventeen places it had been 
vaccinated in, and lymph was taken on December 1, i.e., 
120 hours after vaccination, for the vaccination of another 
child and another calf (994). The child was vaccinated by 
five separate insertions of the lymph, all of which were suc- 
cessful. This child also was kept under observation, and it 
went through a perfectly normal course of vaccination, and 
no small-pox was communicated to others. On December 5, 
ninety-six hours afterwards, two other calves were vaccinated 
from 994, and from this date to May 6, 1886, Simpson's 
lymph was regularly used at Lamb's Conduit Street, concur- 
rently with the Bordeaux lymph, which was that ordinarily- 
used at the station. During this time 1,247 children were 
vaccinated with it and seventy-nine calves. After the use of 
Simpson's lymph, out of the 1,247 children vaccinated with 
it, fifteen were brought back with some abnormality, or 
1*2 per cent. ; and after the use of the Bordeaux lymph, 
which was used concurrently with Simpson's, there were 
eight out of 685 children vaccinated with it brought back to 
the station for a like cause, or 1*16 per cent. 

The writer's insertion success out of 1,174 cases was 98*4 
per cent, with Simpson's, and with Bordeaux, out of 678- 



THE RELATION OF COW-POX TO SMALL-POX 115 

cases, it was 98*2 per cent. Simpson's lymph thus seemed 
a trifle more active than the Bordeaux. 

No case of small-pox was heard of among the children, 
and no case of communication of small-pox to others. 

The following synopsis of the origin and descent of 
Simpson's lymph may prove useful : 



Date. 


Synopsis of the Origin of Simpson's Lymph. 


1885. 
Nov. 10 | 
„ ID 

»; 11 


Small-pox virus obtained from F. P., a female, aged 13. 
1 

Cow inoculated. 


H 17 


1 

15 points charge from the cow vaccinated on the 17th sent 
to Lamb's Conduit Street, from Aberdeen. 


„ 21 


1 

Calf 938, aged 6 months, vaccinated. 
1 


„ 26 


1 1 
Child. Calf 941. 

1 


Dec. 1 


1 1 
Child. Calf 994. 


„ 5 


1 1 
Calf 948. Calf 947. 



From this date to May 6, 1886, Simpson's lymph was used 
regularly at Lamb's Conduit Street. 

Lastly, the writer was associated with Dr. Klein, whose 
paper on the subject is published in the Supplement con- 
taining the Eeport of the Medical Officer of the Twenty- 
second Annual Eeport of the Local Government Board for 
1892-93, in which photographs are reproduced, showing 
the vaccinated arms of the children. The following is a 
synopsis of a portion of his report : 



8—2 



Ii6 THEORY AND PRACTICE OF VACCINATION 



Synopsis of Dr. Klein's Report. 



Date. 


Synopsis of the Origin of Klein's Lymph. 


1892. 
May 31 

„ 31 


Collected small-pox lymph* from (a) L. L., aged 13, unvac- 
cinated, whose initial illness was on May 23,*^and had 
confluent small-pox May 25. 

(b) E. L., aged 32, vaccinated in infancy, initial illness 
May 20, confluent small-pox May 24. This lymph (from 
both cases) was inoculated at the Brown Institution into 


„ 31 


Calf 2. 


June 4 


1 

Calf 4. 


q 


• 

6, transferred to Lamb's Conduit Street. 


„ 13 


i 

8, young bull. 


July 14 


| 

Scab from infant (L.). 


„ 15 


1 

Calf 16, t3 7 pical vaccinia. 


„ 20 


i 

Points. 

1 


„ 20 


1 1 
Infant (L. S.), female. Infant (F. M. B.), female. 



The three children who were vaccinated from this lymph 
series were closely watched, but the vaccination was perfectly 
normal. 

It has been mentioned that the inoculation of small-pox 
on animals is a difficult matter, and only a few succeed. 
Such, however, is not the case when animals are vaccinated 
with current, i.e., humanized lymph. This fact requires 
some consideration, because it can be urged in support of 
the view that small-pox and cow-pox are distinct diseases. 
We have seen that this difficulty is only in the transference 
of small-pox to the animal, and the probable reason is this, 
that the small-pox lymph is taken always from the general 
eruption of small-pox. To make it similar to vaccination 
the lymph should be taken on the eighth day from the mother 

* The lymph was collected at the hospital ship. 



THE RELATION OF COW-POX TO SMALL-POX 117 

vesicle of an inoculated human individual ; but the law does 
not allow this in England. 

Some have held that the cow-pox is sometimes infectious 
among horned cattle. Baron, in his ' Life of Jenner,' p. 234, 
says, ' I think there is good ground for believing that the 
disease as originally noted by Dr. Jenner was the epidemic or 
local remains of the more general or epizootic disease which 
prevailed in many parts of this island at the period when 
Dr. Layard wrote.' 

He here refers to the epidemic described by Dr. Layard,* 
which occurred in 1745 to 1756, and again from 1760 to 
1770. This epidemic Dr. Layard considered to be of the 
variolous kind. He says : ' It bears all the characteristics, 
symptoms, crises, and events of the small-pox, and, whether 
received by contagion or by inoculation, has the same 
appearances, stages, and determinations.' Yet his subse- 
quent description of the disease is not altogether consistent 
with this statement. This opinion of the nature of the 
epidemic continued until 1865, in which year the cattle- 
plague made its appearance in England. It was soon 
recognised to be identical with the disease described by 
Layard, and its likeness to small-pox was again insisted 
upon by several, among whom was Dr. Murchison. 

In the report of Dr. Murchison to the Privy Council, he 
gives this likeness as a reason to try the effect of vaccination 
on the disease ; and again, writing to the Times after this 
had been tried and found of no avail, he says : ' The points 
of resemblance between cattle-plague and small-pox are so 
striking, that certain observers were led to hope that 
vaccination might protect,' etc.t The above quotation is 
sufficient to show that the cattle-plague did bear some 
resemblance to small-pox, but the following established 
points of difference will prove that they are not identical 
diseases, and are not any more related than scarlet fever is 
to measles : 

* Philosophical Transactions for the year 1780. 

f Letter of Dr. Murchison to the Times, January 30, 1866. 



1 1 8 THEORY AND PRACTICE OF VACCINATION 



1st. The amount of the eruption in cattle-plague bears 
no relation to its fatality, which is certainly the case in the 
great majority of the cases of small-pox. 

2nd. The eruption in the two diseases is anatomically 
different. 

3rd. When cattle-plague is conveyed by inoculation from 
one animal to another there is no local development at the 
seat of inoculation, as occurs when small-pox is inoculated. 

4th. Vaccination has been found to afford no protection 
against cattle-plague. 

The epidemics of 1745 and 1760 must not any longer be 
regarded in any way as the small-pox among horned cattle. 

The disease in India known as bussunt, mhata, or gotee,* 
is thus described by Mr. Lamb : ' The animals which were 
at first affected had been for a day or two previously dull 
and stupid. They were afterwards seized with cough, and 
much phlegm collected in their mouths and fauces. The 
animals had at this time no inclination for food. There is 
a discharge of saliva from the mouth, then follow universal 
tremor and great heat of the head, chest, and body, as far 
back as the loins, while the hindquarters are cold. The 
whole body then becomes hot, and the animals suffer from 
intense thirst. The mouth and fauces appear to be the 
principal seat of the disease, being in some instances one 
mass of ulceration. On the fifth day the eruption appears 
about the udder, sometimes only a few pustules, and at 
other times they are numerous and confluent ; but the 
result of the attack does not appear to depend much on the 
eruption. Whether the pustules are numerous or rare, 
the disease is nearly always fatal, and unless measures are 
taken to separate the diseased from the healthy, it speedily 
runs throughout the whole herd, sparing few. 

' In those who do escape after taking the infection the 
favourable symptom is a spontaneous diarrhoea, in which 
the dejections are large, watery, and offensive. Many die 

* Transactions of the Medical and Physical Society of Calcutta, 
vol. viii. 



THE RELATION OF COW-POX TO SMALL-POX 119 



before the eruption makes its appearance, but the fever is 
always known by the discharge of the saliva.' 

Mr. Macpherson, Superintendent of Vaccination at Moor- 
shedabacl, tried inoculating this disease on children in 1832, 
hoping thereby to obtain a new stock of vaccine lymph, and 
he describes his experiments in the following words ' All 
the cattle in the neighbourhood became affected, and, 
amongst others, two belonging to one of my own vaccinators. 
I had them covered with blankets, leaving merely the udder 
and teats exposed to the air. On the seventh day two small 
pustules made their appearance on the teats of one, which 
died upon the tenth, and the crusts were removed on the 
twelfth day. From these crusts eleven native children were 
inoculated, one of them successfully. A vesicle appeared 
on the fifth clay, which continued to increase till the ninth 
day, when it had all the characters of true vaccine ; the 
child suffered much from fever for four days. Two children 
were vaccinated from this vesicle with complete success, the 
symptomatic fever being very severe. From these two 
children five others were successfully vaccinated, and the 
stock thus established was afterwards regularly continued. 
Some of the children vaccinated with the lymph were tested 
by variolous inoculation and exposure to variolous infection 
and found secure.' 

Dr. Seaton, commenting upon the above related experi- 
ments, very justly remarks :f ' From these facts it is not to 
be doubted that a case of cow-pox in the cow had been met 
with ; but what is to be doubted is that the gotee — the 
malignant disease above referred to — was the source of 
infection, for the eruption, so far from being like that 
said to be prevalent, viz., one of pustules all over the 
body, terminating in ulceration, was a couple of pustules 
(vesicles) only, having exactly the characters of an ordinary 

* Transactions of the Medical and Plrysical Society of Calcutta, 
vol. vi., also Duncan Stewart's ' Report on Small-pox, Calcutta,' 1844, 
pp. 84 and 85. 

f Seaton's ' Handbook of Vaccination,' p. 64. 



i2o THEORY AND PRACTICE OF VACCINATION 



case of casual cow-pox.' Dr. Duncan Stewart,* who re- 
ports this case, regrets that information was not given 
more fully regarding the appearance of the disease in 
the cows from which he took the crusts, one of which 
succeeded. 

In 1833 Mr. Furnell,! a civil surgeon of Silhat, in Assam, 
having seen a report of Mr. Macpherson's experiments of 
the preceding year, determined to repeat them. He com- 
menced by vaccinating four children with the scabs taken 
from the back of an animal suffering from gotee, but with- 
out effect. Having shortly afterwards to leave Silhat on 
account of his health, he asked Mr. David Brown, then 
Assistant- Surgeon of the Silhat Light Infantry, to continue 
the experiments. A reward was offered for an animal 
suffering from the disease, which was shortly obtained. 
Nothing, however, is said of the symptoms of the disease 
manifested by the animal, except that it was thin and out 
of condition. It appears, however, that it had a general 
eruption, for scabs were taken from the back of the animal 
and used for the vaccination of four children. All these 
vaccinations were successful. The resulting vesicles are 
said to have run a natural course, and from them four more 
children were vaccinated. Mr. Brown's J words are as 
follows : ' From this new virus vaccination was carefully 
propagated through successive numbers of children by 
either Mr. Furnell or myself, or the native vaccinators 
under our superintendence, through the months of October 
and November.' On November 23, 1833, Major Orchard's 
child and three native children were vaccinated from one 
child with this virus, and on December 1, i.e., on the ninth 
day, Mr. Furnell vaccinated his own child from one of these 
native children. A day or two after this, in due time Major 
Orchard's child had severe small-pox, and the three native 

* Stewart, op. cit., p. 148. 

t Transactions of the Medical and Physical Society of Calcutta, 
Appendix, vol. vii., p. 453, Mr. Furnell's account. 
% Op. cit., vol. viii., p. 97, Mr. Brown's account. 



THE RELATION OF COW-POX TO SMALL-POX 121 



children all had slight but characteristic eruptions. Mr. 
Furnell's child, also, a week after this, had small-pox, of 
which it died on December 20. On making inquiries after- 
wards, Mr. Furnell ascertained that the native child from 
whom he had vaccinated Major Orchard's child and the 
three native children had had a general eruption after 
having been inspected. It could not, however, be ascer- 
tained how many of the native children vaccinated during 
October and November had suffered from small-pox, for no 
register was kept, and the children after vaccination were 
not again seen. Mr. Brown, apologizing for this, says : 
' Why more children were not inspected was owing to no 
register having been kept.' And he goes on to say : ' In 
explanation of this apparent neglect I may state that the 
superintendence of vaccination on Mr. Furnell's part and 
my own was gratuitous, and not considered at the time as 
part of our duties.' 

From the account of these last experiments of Mr. 
Furnell's and Mr. Brown's, it is not unjustifiable to regard 
them as of little or no scientific value : 

(1) Because native vaccinators conducted some, if not 
most, of the vaccinations.* 

(%) No description is given of the symptoms of the 
animal from whom the scabs were taken, save that it was 
thin and out of condition, and incidentally that it had a 
general eruption. 

(3) No register was kept, Mr. Brown apologizing for 
the neglect on the ground that the work was gratuitous. 
So it might have been, but this neglect is unpardonable 
when it is remembered that their work was experimental, 
of which they intended to, and did, publish what results 
they could. 

It is to be remarked that the disease known in India as 
bussunt, mhata, or gotee, as described by Mr. Lamb, bears 
so close a likeness to cattle-plague, that it seems reasonable 

* Tho n-r'nei h&;s been informed, hy a native medical man that many 
of the nat'.V'-js prefer inoci fiat 1 " on \yith small-pox rather than vaccination. 



THEORY AND PRACTICE OF VACCINATION 



to suppose that the disease which Mr. Furnell first witnessed 
was the cattle-plague, and that the see-saw vaccination 
(so-called) between Mr. Furnell and the native vaccinators 
became ultimately inoculation of small-pox. 

It may also be observed that the experiments of Mr. 
Macpherson were made shortly after the publication of 
Dr. Baron's ' Life of Jenner,* who in Chapter V., p. 161, 
gives a most interesting and learned disquisition on the 
history of small-pox, but in which he regards small-pox and 
cattle-plague as identical diseases. 

Such are the leading arguments and facts in favour of 
vaccinia being but a modified form of small-pox, and if 
true, then small-pox is the origin both of cow-pox, horse- 
pox, and camel-pox, and Jenner was most probably correct 
in his observations, but mistaken in their interpretation. 
* This was published in 1827. 



Bailliere, Tindall and Ccn, *20 & 21 ^Kinr, IVUVan-' Pinel' Strand, J.cvdcn. 



p 



( 

r